[B. The Board May Adjudicate Claims Where New Evidence Has Been Obtained If The Appellant Waives Initial Consideration Of The New Evidence By Vba.]

6. The fact that the Board is an appellate body does not preclude it from carrying out the duty to assist with respect to evidentiary development. Unlike appellate courts, appellate administrative bodies ordinarily may obtain or accept additional evidence.

B. The Board may adjudicate claims where new evidence has been obtained if the appellant waives initial consideration of the new evidence by VBA.

[Dro Hearing]

>When I had a 30 percent rating the state reps told me "thats what wrong with the system - people are greedy - you should be happy with the 30 percent"

Unless you hire an attorney to represent you or have the PVA as a service rep, you will likely get low balled. You can expect the guilt treatment, as a tactic to keep vets fron persuing what they are entitled to.

Shake it off

vets are just lazy frauds.

You cant milk the Gov dry.

We're at war you know.

We have others that need the funds.

Too many vets file frivilous claims, clogging the system

You look fit to me. What do you do, work out? Your in great shape........ for having a brain injury, Multiple sclerosis, thyroid disease, spinal stenosis, scoliosis, osteoarthritis, fibromyagia, insomnia, dementia, depression, chronic pain, ataxia, headaches, nausea, bilateral tinnitus & deafness, an arm & leg that doesn't like to move without pain & a leg that I drag & watch jump around when I sit. Hypertention, COAD, and this list goes on.............

>Since I do not have a rep do you think there will be any time allotted for me to discuss issues with the DRO informally?

Don't see why not. At my hearings before the VARO & DRO, both allowed you or them the opportunity to stop the recording & discuss issues & evidence

informally, anytime either party chose.

I've had several hearings and have never met anyone that was rude. They are simply working folks, trying to perform a job under overwhelming circumstances.

Don't expect much to come of it, but it is your best shot.

Allan

[Korean Dioxin/herbicide Veterans]

Korean Dioxin/Herbicide Veterans

The VA just continues with its' injustice.

_http://www.2ndbattalion94thartillery.com/Chas/KoreanDioxinVeterans.htm_'>http://www.2ndbattalion94thartillery.com/Chas/KoreanDioxinVeterans.htm_

(http://www.2ndbattalion94thartillery.com/Chas/KoreanDioxinVeterans.htm)

Kelley

To Congressman Filner and Senator Akaka

Attn: Ms. Sharon Schultze and (yes Ms. Schultze I am angry!)

Ms. Schultze, Please pass this on - that this is why Veterans and their families have an a legitimate grip about how our congress has let Veterans Affairs get a way with compared to what Congress has said they intended for Veterans as well as their families, which at least should be some honesty and integrity by VA.

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Congressman Filner,

You asked for help in your radio broadcast in resolving some of these issues and getting the backlog of claims down.

This is a prime example of a case and similar case that should have been decided at local VA levels in two months time frame; not years and end up at BVA levels.

It is obvious when it comes to the Korean Veterans with herbicide exposures that your dates in your proposed bill is different than the Department of Defense’s cut off dates as I elaborate more on in this case analysis.

I can understand the later date if you are taking into consideration the very minimum half-life of the dioxins. If this is not the case, then something is terribly wrong with our Korean Veterans being denied that would have been inclusive in your bill. I cannot understand the earlier date unless congress has data that the Department of Defense/VA is not passing on to our Veterans and then not applying that in their so-called legal system.

To at least solve the issues with the Korean Herbicide Victims. The inclusive dates should at least be what congress is proposing as law. EPA in their fact sheet records the following technical information. {Reference EPA Technical Fact sheet on: DIOXIN (2,3,7,8-TCDD)} You will note that this EPA fact sheet concludes: (The persistence half-life of TCDD on soil surfaces may vary from less than 1 yr to 3 yrs, but half-lives in soil interiors may be as long as 12 years. Therefore, there could be a difference in whether a victim made surface contact or was involved in soil interior contact in the performance of his or her duties, Veteran or civilian.

What also must be considered is what toxicity was the soil or subsoil at originally. The consideration must be that even at miniscule levels of toxicity can be detrimental. Even two maximum half-lives on surface containments may not be enough to guarantee no damages because of toxicity. This can only be determined by monitoring the soil and subsoil at those areas that were known to be contaminated. When the toxicity is below 5 parts per trillion then at that time according to some studies that should be the cutoff. That seems to meet the consideration and definition of a “low-level exposure.”

As you will see in the review of the one claim the insurmountable legal mandates that VA is putting on the Korean Veterans mostly because of Department of Defense lies and the VA’s mandate to stall and deny to the death of the Veterans.

If the VA had been responsible enough to create at least a presumption of herbicide exposures since the Veterans were in or near where the widespread use of these herbicides was used; then the backlog of BVA claims would not be at the level they are for at least the Korean Veterans. Those units that served on the DMZ have been identified and certainly, that should be enough to prove exposures at soil or subsoil contaminations, much less the water that was, no doubt, contaminated.

The dates of inclusion should be at least your starting date of September 1, 1967, which might also bring in more units as inclusive.

The ending inclusive date just for surface soil or dust contact should be at least three years after the last date of contamination. Given that, congress can get the Department of Defense and its Secretaries to tell the truth.

I am also concerned that the application in Korea was different than Vietnam. Korea seemed to use some form of pellets in their application. While that might have kept down the drift rates one has to wonder what that did to the subsoil. It is doubtful the EPA in their half life technical fact sheet considered that method of application and the resulting leaching over time of the dioxin pellets as opposed to air drying or exposure to sunlight of the normally used liquid mixtures used in farms and of course in Vietnam.

Obviously a few mandates to the VA regarding this issue would make the cases decided at local VA levels and not stalled for decades adding to the already massive amount of back log and continues to grow. Just as obviously for all the wrong reasons.

If you choose to at least consider what I have recommended then all Korean Veteran cases must be mandated for review should you choose to challenge the VA and its lawyers and judges who do not work for the best interest of the Veteran or his family but only for the Department of Defense/VA/White House to keep down the cost of their own mistakes, not the Veterans.

--------------------------------------------------------------------------------

Congressman Filner,

I have another Korean Veteran that developed skin issues in 1979 and now has stage three-lung cancer as well as Chronic Lymphocytic Leukemia – three of which are associated to dioxin exposures. He also is being denied for the same issues as this documented case and that is outside the time line of what this so called court allows. Yet, clearly he would be within your time line in your bill of presumptive exposures in your proposed law. Including he served with one of the outfits that is recognized to have been located in or around the DMZ. The issue is he also was a little outside of what you will see the Court lawyer deems as wide spread usage of herbicides.

I think you will agree that the only reason these men are being denied on the facts is the VA court allows this type of criminal legal behavior to continue, not only in Board lawyers but also Board judges.

Have one of you GAO statisticians do the statistical analysis of the odds of a person developing three associated issues to a single herbicide. The person was known to be in the area of that herbicide. Then calculate the odds of that herbicide not being associated.

In his case, he was on the DMZ on 10/69 to 11/70. Clearly, this is only six to seven months outside the date of what we “think” was the end of spraying. Just as clear this Veteran is inside your proposed bill by at least two years. Yet, the despicable VA denies him.

--------------------------------------------------------------------------------

I would ask all on my e-mail lists to pass this on to their respective congressman and senators also as soon as you can!

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This is a comparison of how our Vets are treated by VA in comparison of how the proposed new Civilian AO bill is worded.

Citation Nr: 0428959

Decision Date: 10/21/04 Archive Date: 10/28/04

DOCKET NO. 03-07 622) DATE

On appeal from the

Department of Veterans Affairs (VA) Regional Office (RO) in

Huntington, West Virginia

THE ISSUE

Entitlement to service connection for diabetes mellitus,

claimed as secondary to herbicide exposure.

REPRESENTATION

Appellant represented by: West Virginia Department of

Veterans Affairs

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

M.Cooper, Counsel

Mr. Cooper, in my opinion, should be charged with incompetence.

INTRODUCTION

The veteran served on active duty from May 1969 to August

1972.

This matter comes before the Board of Veterans' Appeals

(Board) on appeal from a January 2003 RO decision which

denied service connection diabetes mellitus.

A video conference hearing was held in June 2004, before the

Veterans Law Judge signing this document. The Veterans Law

Judge had been designated by the Chairman to conduct the

hearing pursuant to 38 U.S.C.A. § 7102 (West 2002). A

transcript of the hearing testimony has been associated with

the claims file.

FINDINGS OF FACT

1. All relevant available evidence necessary for an

equitable disposition of the appropriate claims addressed by

this decision has been obtained by the RO.

2. The veteran served a part of his active duty in Korea

from 1970 to 1971; he did not serve in the Republic of

Vietnam, and exposure to Agent Orange has not been shown.

…, and exposure to Agent Orange has not been shown.

Does the Veteran have to demonstrate remarkable exposure to toxic chemicals when he was in a known area of usage? An area that is not clearly defined and a Veteran had neither idea of the herbicide usage nor the ramifications of such exposures until decades later. The logical answer should be OF COURSE NOT.

The new proposed Congressional Bill for civilians documents a common sense approach to the issue with the following:

“(II) in or near the Korean demilitarized zone during the period beginning September 1, 1967, and ending on August 31, 1971;”

3. Diabetes mellitus was not evident during service or until

many years thereafter and is not shown to be the result of

any in-service event.

This dumb statement is clearly made by someone who has no idea what in the heck they are talking about in context. Yes, there was no evidence diabetes mellitus until many years after because that is the etiology of the dioxin or herbicide caused diabetes mellitus. Vietnam Veterans coming out of Nam did not develop diabetes until many years or decades later in life. Now this fact is seemingly used against the Veteran in this Kangaroo Court as a negative for him.

CONCLUSION OF LAW

Diabetes mellitus was neither incurred in nor aggravated by

service nor may it be presumed to have been incurred therein.

38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R.

§§ 3.303, 3.307, 3.309 (2003).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

Duty to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA), now

codified as amended at 38 U.S.C.A. §§ 5100, 5102, 5103,

5103A, 5106, 5107, 5126 (West 2002 & Supp. 2004) redefines

the obligations of VA with respect to the duty to assist,

including to obtain medical opinions where necessary, and

includes an enhanced duty to notify a claimant as to the

information and evidence necessary to substantiate a claim

for VA benefits.

VA has a duty to notify the claimant of the evidence needed

to substantiate his claim, of what evidence he is responsible

for obtaining and of what evidence VA will undertake to

obtain. 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v.

Principi, 16 Vet. App. 183 (2002).

The United States Court of Appeals for Veteran Claim's

(Court's) decision in Pelegrini v. Principi, 18 Vet. App.

112, 120-1 (2004) held, in part, that a VCAA notice

consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R.

§ 3.159(b) (2003) (implementing the VCAA) must: (1) inform

the claimant about the information and evidence not of record

that is necessary to substantiate the claim; (2) inform the

claimant about the information and evidence that VA will seek

to provide; (3) inform the claimant about the information and

evidence the claimant is expected to provide; and (4) request

or tell the claimant to provide any evidence in the

claimant's possession that pertains to the claim. This new

"fourth element" of the notice requirement comes from the

language of 38 C.F.R. § 3.159(b)(1).

In correspondence dated in October 2002, the RO provided

notice as to what evidence the veteran was responsible for,

and what evidence VA would undertake to obtain. In the

statement of the case and supplemental statements of the

case, the RO informed the veteran of what the evidence needed

to show, in order to substantiate the claims on appeal.

The October 2002 letter told the veteran to furnish

information with regard to any person having relevant

evidence, and advised him that he could furnish private

records. This information should have put him on notice to

submit relevant evidence in his possession.

In addition, it is noted in Pelegrini, the majority expressed

the view that a claimant was entitled to VCAA notice prior to

initial adjudication of the claim. Pelegrini v. Principi, at

119-20. In this case, the veteran received VCAA notice prior

to the initial adjudication of his claim for service

connection.

Under the VCAA, VA is obliged to provide an examination when

the record contains competent evidence that the claimant has

a current disability or signs and symptoms of a current

disability, the record indicates that the disability or signs

and symptoms of disability may be associated with active

service; and the record does not contain sufficient

information to make a decision on the claim. 38 U.S.C.A.

§ 5103A(d) (West 2002). The evidence of a link between

current disability and service must be competent. Wells v.

Principi, 326 F.3d 1381 (Fed. Cir. 2003).

The veteran has not been provided a VA examination. However,

as will be discussed in greater detail below, there is no

competent evidence that his current diabetes mellitus is

related to service, including as due to herbicide exposure.

In some cases, the veteran's report of a continuity of

symptomatology can serve as competent evidence linking a

current disability to service. Charles v. Principi, 16 Vet.

App. 370 (2002). However, the veteran has not claimed, nor

does the evidence reflect that diabetes mellitus began during

a period of active duty. He instead maintains that his

current diabetes mellitus began many years after his

discharge from active duty and that service connection is for

such is warranted on a presumptive basis due to herbicide

exposure during his service in Korea.

Just as he should be maintaining.

VA has also obtained all relevant treatment records. These

actions have complied with VA's duty to assist the veteran

with the development of his claim. 38 U.S.C.A. § 5103A (West

2002).

I can testify anytime that Congressman Filner or any other oversight committee wants that the above topic of “Duty to Notify and Assist” is garbage. I did all of the above, brought my evidence to my BVA with a prepared 20-minute presentation, and was denied by the Veterans Affair judge that did not want to hear my data and evidence regarding my case. I would assume she was late for her flight back to DC. My wife had a shopping cart full of data, statistics, Ranch Hand transcripts, and congressional transcripts, study data of both civilian and Vietnam Veterans. After waiting for five years, this judge denied me that right. Therefore, this topic should include a disclaimer by the Secretary of the VA that any data collected for your case “shall not be allowed to be presented under oath,” as the VA really does not want nor care about justice - only management bonuses!

Factual Background

A review of his service medical records is entirely negative

for treatment, complaints, or clinical findings of diabetes

mellitus or symptoms of any endocrine disorder.

Just as it should be!

Service personnel records reflect that the veteran served on

active duty in Korea from March 1970 to April 1971. He also

served in Germany from May 1971 to April 1972. No other

periods of overseas active duty service have been shown.

Private medical records dated from March 1999 to June 2001

reflect that the veteran's blood glucose readings were

consistently within normal limits.

Once again, the above statement because of the continuous Department of Defense study lies means nothing to this case for this veteran when discussing Diabetes Mellitus for the toxic chemical exposed Veteran. Why?

Here is why?

In several Ranch Hand transcripts, there were discussions of why 37% of those cohorts that were diagnosed with diabetes mellitus yet testing for A1C were normal. In fact, if the Veteran were not tested properly, at the proper insulin cycle timing the testing would be normal. However, when looked at in a different form of testing such as an oral testing the pattern of non-insulin control is clear. Of course one of the ramifications of this is damage is being done long before, in many cases by accident, the testing is done at the right time and the right conditions and only then detecting the insulin issues and more than likely the insulin resistance creating damages in nerve, vascular, and/or kidney disease.

VA medical records dated from January 2002 to August 2002

reflect treatment for a variety of disorders including

diabetes mellitus, hypertension, obesity, atypical chest

pain, and degenerative joint disease. On VA Agent Orange

examination in July 2002, the veteran related that the served

in Korea from 1969 to 1970 as a combat engineer. He

indicated that he recalled spraying Agent Orange but did not

handle it. The diagnostic assessment included non-insulin

dependent diabetes mellitus, diet controlled with no family

history of diabetes. The examiner indicated that such could

be related to Agent Orange.

We know by VA’s own Dr. Kang’s recent studies that hypertension was found significant, the joint issues are also common with Vietnam Veterans and has been known since 1985 (with or without diabetes), we also know that lipid metabolism issues are a result of the exposures. We also know by other studies done on their Vietnam Veterans that cardiovascular issues are significant. If not for the Department of Defense lies and the flawed Ranch Hand study, we would know from our own government entities.

The veteran submitted copies of Internet articles related to

the use of Agent Orange during the Vietnam War. The articles

noted that use of herbicides has been shown to result in a

wide range of organ and metabolic dysfunctions.

The Veteran used Internet articles because of once again of the continuous Department of Defense study lies.

In his February 2003 notice of disagreement, the veteran

indicated that he served in Korea from April 1970 to March

1971; one year after use of Agent Orange was discontinued in

the demilitarized zone (DMZ) in Korea. He stated that he

participated in the construction of a chain link fence which

involved digging holes several feet deep into soil that, he

alleged, had been contaminated the previous year by Agent

Orange. The veteran maintained that he was exposed to Agent

Orange at that time.

Even this is not needed for exposure verification. If the Veteran was in or close to an area that was sprayed he was exposed. If he drank the water, he was exposed. If he rode on a dirt road with any dust particles, he was exposed reference Times Beach, Missouri. If he rode in a convoy he was exposed to possible, dioxins mixed with fuel (reference Emergency MACV Directive to all commands in 1969 issued by Fort Detrick, Maryland on proper decontamination before used in PLO storage).

In his substantive appeal, the veteran contended that he

served in the DMZ in Korea only a year after widespread use

of Agent Orange had been discontinued.

He asserted that

since the chemical half-life of Agent Orange was three years,

it was as deadly as the day it was sprayed.

The Veteran is correct! {Reference EPA Technical Fact sheet on: DIOXIN (2,3,7,8-TCDD)} You will note that this EPA fact sheet concludes: (The persistence half-life of TCDD on soil surfaces may vary from less than 1 yr to 3 yrs, but half-lives in soil interiors may be as long as 12 years. Screening studies have shown that TCDD is generally resistant to biodegradation.) Even this fact is probably minimized. Nevertheless, lets look at it logically and conclude that yes, it was even one year or six months even. No dose rate has been established for diabetes regardless of what the toxicity was when the soldier was there; only that it was there. What difference does it make in a legal case unless the denying VA can prove the half life at the time of exposures was not sufficient enough to create any associated dioxin or herbicide disorders? The logical real legal system would presume that the givens point to known exposures. Exposures known to cause the disorders at any level of exposure, everyone is different biologically.

During the June 2004 videoconference hearing, the veteran

testified that he was diagnosed with diabetes mellitus during

an Agent Orange examination. He said that he worked as a

truck driver during active service and was involved in

transporting workers as they sprayed chemicals on the

perimeter of the demilitarized zone. He did not know what

the chemicals were, but believed they were herbicides. He

again reported that he had been involved in digging fence

posts along the demilitarized zone in Korea. He stated that

there was no history of diabetes mellitus in his family, with

the exception of his brother who served in Vietnam.

Legal Criteria

Service connection may be granted for disability resulting

from personal injury suffered or disease contracted during

active military service, or for aggravation of a pre-existing

injury or disease during such service. 38 U.S.C.A. § 1110;

38 C.F.R. §§ 3.303.

Service connection may also be granted for any disease

initially 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).

A disease associated with exposure to certain herbicide

agents, listed in 38 C.F.R. § 3.309 will be considered to

have been incurred in service under the circumstances

outlined in this section even though there is no evidence of

such disease during the period of service. No condition

other than one listed in 38 C.F.R. § 3.309(a) will be

considered chronic. 38 U.S.C.A. §§ 1112, 1113, 1116 (West

2002); 38 C.F.R. §§ 3.307, 3.309 (2003).

A veteran who, during active military, naval, or air service,

served in the Republic of Vietnam during the Vietnam era

shall be presumed to have been exposed during such service to

a herbicide agent, unless there is affirmative evidence to

establish that the veteran was not exposed to any such agent

during that service. 38 U.S.C.A. § 1116(f); 38 C.F.R.

§§ 3.307, 3.309.

Another issue regarding our Korean Veterans that were exposed. For Vietnam Veterans the rule is as follows:

Vietnam-era Veterans are presently defined as persons who served on active duty for more than 180 days, any part of which occurred between February 28, 1961 and May 7, 1975, ….

Clearly using the board counselor’s own words, this is inclusive four years after wide spread usage of herbicides was supposedly according to the Department of Defense, terminated. Yet, the VA’s legal beagle can state that the Korean Veterans exposures were one year after supposedly the widespread spraying of herbicides was suspended. The key word here being in legal terms “the widespread usage.” Therefore, he has to prove some form of half-life correlation and such. Why do the Vietnam Veterans get a four year pass and yet the Korean Veterans cannot even get a six month pass serving after the date of supposedly stopping the wide spread defoliant usage. Obviously, because of half-life and the fact no one without divine intervention can say, what toxicity level is required for any one disorder. That lack of divine intervention must apply to this Counselor and this JUDGE; as well as the President of United States who directs and appoints the Secretary of this run away outfit.

The last date on which a veteran shall be presumed to have

been exposed to an herbicide agent shall be the last date on

which he or she served in the Republic of Vietnam during the

Vietnam era. "Service in the Republic of Vietnam" includes

service in the waters offshore and service in other locations

if the conditions of service involved duty or visitation in

the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii).

If a veteran was exposed to an herbicide agent during active

military, naval, or air service, diabetes mellitus shall be

service-connected if the requirements of § 3.307(a)(6) are

met even though there is no record of such disease during

service, provided further that the rebuttable presumption

provisions of § 3.307(d) are also satisfied. 38 C.F.R.

§ 3.309(e).

Diabetes mellitus is subject to the presumption in 38 C.F.R.

§ 3.309(e) if it become manifest to a degree of 10 percent or

more at any time after service. 38 C.F.R. § 3.307(a)(6)(ii).

Analysis

The veteran has made varying contentions as to his exposure

to Agent Orange in Korea. On the one hand, he has argued that

he was exposed directly to the defoliant through being around

those who were using it. On the other hand, he seems to

concede that the use of Agent Orange had ceased by the time

he arrived in Korea, but asserts that he was exposed to

residual defoliant in the soil and in plant material.

Service department records show some use of Agent Orange in

parts of Korea during 1968 and 1969. They do not show the

use of Agent Orange or similar herbicides thereafter. Thus,

the evidence is against a finding that he was exposed to

direct spraying of Agent Orange.

The exact dates of the Department of Defense admissions was Agent Orange was used along Korea's DMZ from April 1968 through July 1969 to defoliate the fields of fire between the front line defensive positions and the south barrier fence.

As with any herbicide admissions for the Department of Defense it took decades for them to admit this after the evidence became so overwhelming - denial was no longer plausible. No Veteran or their family believes the Department of Defense in these herbicide issues any longer. They lied about Laos (Corona Harvest), Cambodia (Corona Harvest), Guam, and Korea for decades while Veterans died. Congress should no longer believe them either.

As a layperson, the veteran is not competent to say that

diabetes mellitus was caused by residual Agent Orange in the

environment after its use had been stopped.

I would suggest if not for this “kangaroo court” this lawyer and this judge are not competent to rule in this case of herbicides.

An opinion on

this question would require scientific knowledge as to the

residual Agent Orange in the veteran's environment in Korea,

and medical knowledge of the likelihood that such residual

exposure could cause diabetes mellitus.

This is totally absurd! No scientists or even research institute in the entire world in 60 years have been able to do what this yahoo board lawyer is even suggesting this Veteran needs to prove.

The veteran has submitted articles regarding the half-life of

Dioxin, and its residual presence in the environment. These

articles do not contain any specific information as to the

veteran's exposure in Korea, or the likelihood that such

exposure caused diabetes mellitus.

Why would that possibly be? Could it be the Department of Defense lied for decades about even using any herbicides in Korea? We have 2.7 million Veterans that the United States Government has deemed that exposures to the exact same herbicide does indeed cause a number of medical issues (and there should be more) including diabetes mellitus. Should it make any difference if it was in Vietnam or Korea? Of course not. Only in this so-called court does it make a difference.

The medical evidence of record shows no complaints or

manifestations of diabetes mellitus while on active duty. On

examination for separation from service, in February 1972,

urinalysis was negative for sugar and blood testing showed

sugar levels to be normal. Post-service medical evidence

includes private treatment records, which show no diagnosis of

diabetes mellitus and blood glucose values which were

consistently within normal limits. VA medical records show a

diagnosis of non-insulin dependent diabetes mellitus,

beginning in 2002.

Again, as would be typical for dioxin associated diabetes mellitus.

As the veteran did not serve in the Republic of Vietnam, or

in Korea during the period when Agent Orange was used, he

does not qualify for presumptive service connection for

diabetes mellitus. As no other connection between current

diabetes and service is shown, service connection is denied.

Again, this is a totally absurd legal defense in denial. He was not there during what the Department of Defense has admitted to from April 1968 through July 1969. Yet, he did serve in Korea from 1970 to 1971 as a combat engineer according to the board lawyer. It would be nice if the board lawyer would have put in the month and date as the time frame may have only been 6 months after the wide spread (cough cough) usage of defoliants was terminated.

What is interesting in Congressman Filner’s sponsored bill for Civilian AO exposures is the inclusive dates of being “on or near the DMZ.” These dates are:

(II) in or near the Korean demilitarized zone during the period beginning September 1, 1967, and ending on August 31, 1971;

The question must be asked. Is the congress now aware of spraying issues that the Department of Defense has not made aware (or lied) to Veterans or their families? The dates congress has inclusive would have proven this Veterans claim given the same levels of evidentiary findings and law provided by the congress.

The difference between April 1968 start date and the congresses start date of September 1, 1967 and the ending date of July 1969 versus congresses law of August 31 1971 can make a big difference to those that served this nation’s military and their Department of Defense created widows.

ORDER

Entitlement to service connection for diabetes mellitus, as

secondary to herbicide exposure is denied.

____________________________________________

Mark D. Hindin

Veterans Law Judge, Board of Veterans' Appeals

Mr. Hindin, in my opinion, could not judge a pie-eating contest fairly.

Department of Veterans Affairs

YOUR RIGHTS TO APPEAL OUR DECISION

The attached decision by the Board of Veterans' Appeals (BVA or Board) is

the final decision for all issues addressed in the "Order" section of the

decision. The Board may also choose to remand an issue or issues to the

local VA office for additional development. If the Board did this in your

case, then a "Remand" section follows the "Order." However, you cannot

appeal an issue remanded to the local VA office because a remand is not a

final decision. The advice below on how to appeal a claim applies only to

issues that were allowed, denied, or dismissed in the "Order."

If you are satisfied with the outcome of your appeal, you do not need to do

anything. We will return your file to your local VA office to implement

the BVA's decision. However, if you are not satisfied with the Board's

decision on any or all of the issues allowed, denied, or dismissed, you

have the following options, which are listed in no particular order of

importance:

? Appeal to the United States Court of Appeals for Veterans Claims

(Court)

? File with the Board a motion for reconsideration of this decision

? File with the Board a motion to vacate this decision

? File with the Board a motion for revision of this decision based on

clear and unmistakable error.

Although it would not affect this BVA decision, you may choose to also:

? Reopen your claim at the local VA office by submitting new and

material evidence.

There is no time limit for filing a motion for reconsideration, a motion to

vacate, or a motion for revision based on clear and unmistakable error with

the Board, or a claim to reopen at the local VA office. None of these

things is mutually exclusive - you can do all five things at the same time

if you wish. However, if you file a Notice of Appeal with the Court and a

motion with the Board at the same time, this may delay your case because of

jurisdictional conflicts. If you file a Notice of Appeal with the Court

before you file a motion with the BVA, the BVA will not be able to consider

your motion without the Court's permission.

How long do I have to start my appeal to the Court? You have 120 days from

the date this decision was mailed to you (as shown on the first page of

this decision) to file a Notice of Appeal with the United States Court of

Appeals for Veterans Claims. If you also want to file a motion for

reconsideration or a motion to vacate, you will still have time to appeal

to the Court. As long as you file your motion(s) with the Board within 120

days of the date this decision was mailed to you, you will then have

another 120 days from the date the BVA decides the motion for

reconsideration or the motion to vacate to appeal to the Court. You should

know that even if you have a representative, as discussed below, it is your

responsibility to make sure that your appeal to Court is filed on time.

How do I appeal to the United States Court of Appeals for Veterans Claims?

Send your Notice of Appeal to the Court at:

Clerk, U.S. Court of Appeals for Veterans Claims

625 Indiana Avenue, NW, Suite 900

Washington, DC 20004-2950

You can get information about the Notice of Appeal, the procedure for

filing a Notice of Appeal, the filing fee (or a motion to waive the filing

fee if payment would cause financial hardship), and other matters covered

by the Court's rules directly from the Court. You can also get this

information from the Court's web site on the Internet at

www.vetapp.uscourts.gov, and you can download forms directly from that

website. The Court's facsimile number is (202) 501-5848.

To ensure full protection of your right of appeal to the Court, you must

file your Notice of Appeal with the Court, not with the Board, or any other

VA office.

How do I file a motion for reconsideration? You can file a motion asking

the BVA to reconsider any part of this decision by writing a letter to the

BVA stating why you believe that the BVA committed an obvious error of fact

or law in this decision, or stating that new and material military service

records have been discovered that apply to your appeal. If the BVA has

decided more than one issue, be sure to tell us which issue(s) you want

reconsidered. Send your letter to:

Director, Management and Administration (014)

Board of Veterans' Appeals

810 Vermont Avenue, NW

Washington, DC 20420

VA

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CONTINUED

Remember, the Board places no time limit on filing a motion for

reconsideration, and you can do this at any time. However, if you also plan

to appeal this decision to the Court, you must file your motion within 120

days from the date of this decision.

How do I file a motion to vacate? You can file a motion asking the BVA to

vacate any part of this decision by writing a letter to the BVA stating why

you believe you were denied due process of law during your appeal. For

example, you were denied your right to representation through action or

inaction by VA personnel, you were not provided a Statement of the Case or

Supplemental Statement of the Case, or you did not get a personal hearing

that you requested. You can also file a motion to vacate any part of this

decision on the basis that the Board allowed benefits based on false or

fraudulent evidence. Send this motion to the address above for the

Director, Management and Administration, at the Board. Remember, the Board

places no time limit on filing a motion to vacate, and you can do this at

any time. However, if you also plan to appeal this decision to the Court,

you must file your motion within 120 days from the date of this decision.

How do I file a motion to revise the Board's decision on the basis of clear

and unmistakable error? You can file a motion asking that the Board revise

this decision if you believe that the decision is based on "clear and

unmistakable error" (CUE). Send this motion to the address above for the

Director, Management and Administration, at the Board. You should be

careful when preparing such a motion because it must meet specific

requirements, and the Board will not review a final decision on this basis

more than once. You should carefully review the Board's Rules of Practice

on CUE, 38 C.F.R. 20.1400 -- 20.1411, and seek help from a qualified

representative before filing such a motion. See discussion on

representation below. Remember, the Board places no time limit on filing a

CUE review motion, and you can do this at any time.

How do I reopen my claim? You can ask your local VA office to reopen your

claim by simply sending them a statement indicating that you want to reopen

your claim. However, to be successful in reopening your claim, you must

submit new and material evidence to that office. See 38 C.F.R. 3.156(a).

Can someone represent me in my appeal? Yes. You can always represent

yourself in any claim before VA, including the BVA, but you can also

appoint someone to represent you. An accredited representative of a

recognized service organization may represent you free of charge. VA

approves these organizations to help veterans, service members, and

dependents prepare their claims and present them to VA. An accredited

representative works for the service organization and knows how to prepare

and present claims. You can find a listing of these organizations on the

Internet at: www.va.gov/vso. You can also choose to be represented by a

private attorney or by an "agent." (An agent is a person who is not a

lawyer, but is specially accredited by VA.)

If you want someone to represent you before the Court, rather than before

VA, then you can get information on how to do so by writing directly to the

Court. Upon request, the Court will provide you with a state-by-state

listing of persons admitted to practice before the Court who have indicated

their availability to represent appellants. This information is also

provided on the Court's website at www.vetapp.uscourts.gov.

Do I have to pay an attorney or agent to represent me? Except for a claim

involving a home or small business VA loan under Chapter 37 of title 38,

United States Code, attorneys or agents cannot charge you a fee or accept

payment for services they provide before the date BVA makes a final

decision on your appeal. If you hire an attorney or accredited agent within

1 year of a final BVA decision, then the attorney or agent is allowed to

charge you a fee for representing you before VA in most situations. An

attorney can also charge you for representing you before the Court. VA

cannot pay fees of attorneys or agents.

Fee for VA home and small business loan cases: An attorney or agent may

charge you a reasonable fee for services involving a VA home loan or small

business loan. For more information, read section 5904, title 38, United

States Code.

In all cases, a copy of any fee agreement between you and an attorney or

accredited agent must be sent to:

Office of the Senior Deputy Vice Chairman (012)

Board of Veterans' Appeals

810 Vermont Avenue, NW

Washington, DC 20420

The Board may decide, on its own, to review a fee agreement for

reasonableness, or you or your attorney or agent can file a motion asking

the Board to do so. Send such a motion to the address above for the Office

of the Senior Deputy Vice Chairman at the Board.

VA

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[Dro Hearing]

>*The DRO in conducting a De Novo Review confirmed the original rater’s decision.

This is very common Ricky. "Rubber stamped" ratings. I have several.

Since there was absolutely no discussion of any evidence in the reason and bases what evidence is in the file that would out weigh and negate the statements and opinions of these highly qualified medical professionals? There is none!

Another common rating practice. Been there. It knocks the wind out you, once you to realize, just how much of this is business as usual.

THIS, is what CONGRESS allows the VA to call, an honest evaluation of ALL the evidence?

Remember this. If testimony is not given under oath & recorded, the VA does not have to consider the testimony as being," a PART OF THE RECORD".

What isn't part of the record, may be set asside. so if your offered an"INFORMAL" hearing, don't except. Always request a "FORMAL" hearing, followed up with a written reqeust for a paper cpoy of the transcription. You must be sworn in, under oath & recorded at a formal hearing.

Wonder if the VA or NSO's have a recorder vets can use in the VARO buildings?

Allan

PS........you may want to write it all down in a signed statement before you go. Than just read the statement during the recording, submit your evidence & give a signed copy to your service rep & another to the hearing officer. After you read it. Ask your questions, & listen to theirs. If you don't hear well or don't understand things clearly, take someone with you to help. It's allowed.

[5.20 Medical Evidence Of Probable Entitlement]

as cheaply as possible?

Is our rating process modeled after our health care, or vise versa?

Hello John,

I don't see anything going on at the VA now, but bidness as usual.

MANY, will suffer if left in the hands of those who care for us. Congress must take a stand & develope laws to protect us or take the credit for toturing us.

It's in their hands.

Berta,

I will try to finish my letter concerning 30day time limit & SSOC & get it in ASAP. I put little faith in letter writing as most of you know, but believe in what you say Berta. So I' will make more of an effort to make a written paper trail.

Would you mind viewing it & giving comment, before I send it off? I don't mind the VA & most of the veteran comunity thinking I'm crazy. That's a normal reaction to decades of the claims process I think. For Vets, NSO's & VA personel.

Im not comfortable with the entire nation knowing it for sure, once they read my thoughts.

Allan

[Answered Questions]

Hello Marie,

the VA is allowed to send your claims file to a medical consultant for an opinion. You do not have to be examined, nor do have to send the whole C-file for them to view.

They are allowed to pick & choose what evidence is "considered" as evidence for or against you.

Veterans are allowed to have their records examined by a consultant also & can pay for their own IMO.

DR Bash. He's one of the specialists in the field, that the Court of appeals uses in complex cases where the DVA needs an opinion to decide if its service connected or not & or privide a diagnoses.

You can email him & fax him a few key pieces of evidence proving what your claiming service connection for. If you have a case he can say yeaon & theres supportive medical evidence, he writes the IMO(independent medical opinion).

If you don't have the evidence to support a claim, I don't think he charges you anything, but you will get a reply from him explaining what he needs & what his currant fee's are.

He's one of maybe 1000 across the country.

allan

[5.20 Medical Evidence Of Probable Entitlement]

I would prefer to sue them under Class Action and if they have hurt other vets and widows in this state ,that can be done.

Hello Berta,

I'm in the same situation when it comes to Dr Bash's IMO's not being excepted as evidence at the RO level. They refuse to give weight to their own C&P examiners opinions, privite treatment records over a 30 yr span & treating Dr's opinion, which supports the VA's C&P examiners favorable opinion..

Remands from the BVA & their instructions are being completely ignored. Nearly a yr ago, the BVA remanded back to the Appeals Center, stating the RO was in violation of law for not viewing, listing or granting weight to favorable evidence. It's completely obvious to me, that what is being done, is illegal. It's called obstruction of justice & possibly theft of funding for veterans.

How in the world are these people allowed to steal from disabled veterans & their families, do it repeatly to vets across this country, & no one in Congress lifts a hand to stop it?

I do not live in your state, but will send a noterized statement if it will help. If it turns into a nation wide class acction, I would like to join in. I say put some of these bums in a federal prison.

Allan

[Prevalence And Characteristics Of Chronic Pain In Veterans With Spinal Cord Injury]

Could you be a little more specific as to why justification for the post is needed?

Does expensive health care research conducted by the VA concerning spinal cord injuries belong in this forum? Or would you like it put somewhere else?

["secondary Mood Disorder Due To A General Medical Condition."]

Clinical Psychopharmacology Seminar 1996-1997

Efficacy of Antidepressants in Medically Ill Patients

Paul J. Perry, Ph.D., Bruce Alexander, Pharm.D., Vicki L. Ellingrod, Pharm.D.

Peer Review Status: Not Peer Reviewed

Diagnosis of Depression in Patients with Medical Illness (DSM-IV, 1993)

Patients with both a medical illness and depression present a diagnostic and treatment challenge. Combined illness is not an uncommon problem for physicians. Surveys of patients seen in medical settings found a majority of depressed patients have a comorbid medical diagnosis. The comorbid illness may effect recovery of the depressed patient. Keitner et al. (1991) studied 78 patients meeting DSM-IIIR criteria for major depression. Forty-one had their major depression compounded by a coexisting axis-I (dysthymia, substance abuse, anxiety disorder, OCD, bulimia), axis-II , or axis-III (cardiovascular disorder, diabetes, epilepsy, asthma, chronic pain) diagnosis. There was no specific mention of the antidepressive treatments applied only that no significant difference existed between the pure depression versus compound depression groups. The patients were monitored for a 12 month period, initially as inpatients and then as outpatients using the HAM-D and GAS. They reported that the patients with compound depression recovery rate of 33% was significantly lower than the "pure" depression recovery rate of 65%. There was no difference in the recovery rates within the groups of patients with compound depression. Thus as patient with MDD and angina had the same probability of recovery as a patient with MDD and OCD, or MDD and schizotypal personality disorder. Instead the authors noted that the limiting factor for a positive antidepressant response was number of life events. Thus the patients with the fewest number of life events such as patients with pure depression were the most likely to response to therapy. Importantly, only the number and not the nature of the life events could predict recovery. Thus it can be hypothesized that in the treatment of depressed patients with concomitant medical illnesses the prognosis for recovery may well decrease the more severe the illness is in the patient. There are numerous medical illnesses below in which the depressed patients have been treated with antidepressants. This review has collated the antidepressant efficacy in the treatment of depressed medically ill patients.

When depression is seen in the medically ill, the following diagnostic possibilities need consideration and investigation:

a. Major depressive episode independent of the medical condition

b. Adjustment Disorder with Depressed Mood from the stress of the medical illness precipitating a depressed mood

c. Secondary Depression Due to the Medical Condition - when the medical illness precedes the depression and is felt to have an etiologic (pathophysiologic) relationship to the depression

d. Substance-induced Depression - alcohol, drug or prescription medication produces a depressed mood

e. Depression symptoms is that are a normal response to the effect of being severely ill

Compounding the problem of assessment is the changing of diagnostic nomenclature from DSM-IIIR to DSM-IV for identifying the relationship between medical illness and depression. DSM-IIIR identified a category of depression called organic mood syndrome, depressed type. The name had been changed from organic affective disorder in DSM-III. This category was defined describing a "prominent and persistent depressed mood" with "evidence from the history, physical examination or laboratory tests of a specific organic factor judged to be etiologically related to the disturbance." In DSM-IV the term organic will be deleted from a variety of conditions. The section "Organic Mood Syndromes and Disorders" is also being deleted. Specific psychiatric syndromes such as depression felt due to organic factors are grouped into the Mood Disorders with a renamed category - "Secondary mood disorder due to a general medical condition." The proposed criteria for this disorder is listed in the table along with the other DSM-IV diagnoses to consider in medical patients presenting with depression.

Proposed DSM-IV Categories for Depression and Medical Illness*

Major Depressive Episode

A. At least five of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood (2) loss of interest or pleasure.

1. depressed mood most of the day, nearly every day as indicated by either subjective report or observation by others

2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3. significant weight loss or weight gain when not dieting (> 5% body weight in a month) or decrease or increase in appetite nearly every day

4. insomnia or hypersomnia nearly every day

5. psychomotor agitation or retardation nearly every day (observable by others not merely subjective feelings of restlessness or being slowed down

6. fatigue or loss of energy nearly every day

7. feelings of worthlessness or excessive or inappropriate guilt nearly every day

8. diminished ability to think or concentrate, or indecisiveness, nearly every day

9. recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or plan for committing suicide

B. The disturbance causes marked distress or significant impairment in social or occupational functioning

C. Not due to a Substance-induced or Secondary Mood Disorder

D. Not within 2 months of the loss of a loved one (except if associated with marked functional impairment, the presence of morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation).

Secondary Mood Disorder Due to a General Medical Condition (293.83)

A. A prominent and persistent disturbance in mood characterized by either (or both) of the following:

1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities

2. elevated, expansive, or irritable mood

B. There is evidence from the history, physical examination, or laboratory findings of a general medical condition judged to be etiologically related to the mood disturbance.

C. The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder with Depressed Mood, in response to the stress of having a general medical condition.

D. disturbance causes marked distress or significant impairment in social or occupational functioning.

E. The disturbance does not occur exclusively in the course of delirium or dementia

Specify type: with manic features, with depressed features, with mixed features

Substance-induced Mood Disorder (29x.)

A. A prominent and persistent disturbance in mood characterized by either (or both) of the following:

1. depressed mood or markedly diminished interest or pleasure in all, or almost all, activities

2. elevated, expansive, or irritable mood

B. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in A developed during intense substance intoxication or withdrawal, or occurred within a month of the cessation of intoxication or withdrawal.

C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include: the symptoms precede the onset of the substance abuse or dependence; persist for a substantial period of time (e.g. about a month) after the cessation of withdrawal or severe intoxication; are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non-substance-induced mood disorder (e.g., history of recurrent mood episodes).

D. The disturbance causes marked distress or significant impairment in social or occupational functioning

E. The disturbance does not occur exclusively during the course of Delirium.

Specify: (Specific Substance) (Intoxication/Withdrawal) Mood Disorder

Specify type: with manic features, with depressed features, with mixed features

Adjustment Disorder with Depressed Mood (309.0)

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s), which occurs within three months of the onset of the stressor (2).

B. These symptoms or behaviors are clinically significant as evidenced by either of the following:

1. marked distress that is in excess of what would be expected from exposure to the stressor

2. significant impairment in social or occupational (academic) functioning

C. The stress-related disturbance does not meet the criteria for any specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

D. Does not represent Uncomplicated Bereavement

E. The symptoms do not persist for more than six months after the termination of the stressor. It is not uncommon to experience major depression secondary to a psychiatric disorder or a medical illness

ORGANIC MOOD DISORDER

Yates et al.(1991) compared 50 patients with depression secondary to medical illness (MDD/MI) to 50 patients with organic mood disorder (OMD). Organic mood disorder assumes that the pathophysiology of the primary medical illness (e.g., cerebrovascular accident, epilepsy, corticosteroid use, multiple sclerosis, head trauma, brain cancer, cerebral palsy, etc.) directly causes the mood disorder. Depression in the medically ill occurs without a major medical pathophysiologic mechanism (e.g., diabetes, hypertension, coronary artery disease, atypical chest pain, obesity, prostate cancer, hypothyroidism, etc.). Of the OMD group and MDD/MI group 76% and 80% respectively received a trial of a TCA. Trial adequacy was defined as imipramine or its equivalent 150 mg per day for eight weeks. The number of patients who received an adequate trial in the OMD and MDD/MI group was 34% and 34% respectively. For all patients 11% of the OMD and 59% of the MDD/MI experienced a full recovery. Thus it would seem that medical illnesses that affect the CNS by causing clinical depressions are far less likely to respond to antidepressant treatment than depressed patients who have concomitant medical illness that do not affect the CNS. If this hypothesis is correct one should observe negative antidepressant treatment studies for OMD and positive treatment studies for MDD/MI.

Organic Mood Disorder - Treatment Studies

Stroke

It is estimated that post-stoke depressions occur in 26-50% of patients (Robinson et al 1984, Feible and Springer 1982). Thus the treatment of this disorder is a very practical consideration in the rehabilitation of these patients.

Lingham et al (1988) examined the records of 25 post-stroke patients who met the DSM-III criteria for depression. All were treated with methylphenidate 15-40 mg/d (mean = 26 mg/d). According to the information distilled from the progress notes, the patients were classified as responders or nonresponders. Thirteen (52%) of the patients recovered completely from depression. Mood demonstrated an improvement in the responders usually within 48 hours. Two patients with a history of cardiac disease had cardiac side effects from the drug and one patient had visual hallucinations which stopped after the methylphenidate dose was decreased. Thus although open trials suggest a role for methylphenidate in the treatment of post-stroke depression confirmation with a placebo controlled trial is still necessary.

Balunov et al (1990) contrasted the use of amitriptyline (n = 30) to two minor tranquilizers (n = 30), seduxen and or sibazone, or no pharmacotherapy (n = 30) in the treatment of 90 post-stroke depressed patients. No diagnostic depression criteria were utilized. However, the 90 patients mean HAM-D score was approximately 13 ± 1 suggesting the patients were only mildly depressed. The amitriptyline dose was titrated from 25 mg in week-1, 50 mg week-4 and 4, and 75 mg during week 4. At week-4 of therapy, amitriptyline HAM-D scores were significantly lower when compared to the two other treatments. No significant difference was found between seduxen and placebo.

Murray et al (1986) reviewed the charts of 14 patients who received ECT after post-stroke depression (13). Between 3-18 treatments were administered. Twelve of the patients were characterized as markedly improved. One patient was described as showing little improvement while the other patient response was unknown. One patient with CV disease developed a transitory arrhythmia during ECT. No patients were noted to have any worsening of their neurologic status. Finklestein et al (1987) also conducted a retrospective chart review to contrast the effectiveness of antidepressants in the treatment (doxepin, maprotiline, trazodone, desipramine, amitriptyline, imipramine, and nortriptyline) of 42 depressed post-stroke patients to 18 post-stroke patients receiving no treatment for 6 weeks. Patients met criteria for major depression (DSM-III). Seventeen (33%) of the antidepressant responded to pharmacotherapy. However, there was no difference in the final depression scores between the two treatment groups. The antidepressant doses between the responders and nonresponders according to imipramine equivalents differed from 68 mg/d in the responders versus 50 mg/d (p < 0.07) in the nonresponders. These findings may be biased by the fact that the antidepressant doses were by subtherapeutic.

There are two controlled double-blind trials that have evaluated the effectiveness of antidepressant therapy in stroke patients. Lipsey et al (1984) compared 4 or 6 weeks of nortriptyline treatment to placebo in 39 patients with post-stroke depression (Lipsey et al 1984). The nortriptyline dose was titrated to 100 mg/d over a 4-week period. Twenty-six patients (11 nortriptyline and 15 placebo) completed the entire study. Patients who given nortriptyline showed a significantly greater improvement in both the HAM-D scores (p = 0.06) and the Zung scores (p = 0.02) than patients who were on placebo. Unlike the previous negative study were antidepressant dose was a potentially confounding issue these patients received therapeutic doses which may be why the study was positive. Reding et al (1986) studied 27 post-stroke with either major depression or dysthymia (DSM-III) patients in a double blind study comparing trazodone to placebo. Barthel ADL scores improved significantly only in the patients with the abnormal DST treated with trazodone 32 days of treatment.

Summary. Depression following stroke is not fully explained as a psychological response to the associated impairment. There appear to be subgroups of depressed post-stroke patients whose depression is causally related to the injury, possibly including its strategic location in the brain (left dorsal lateral frontal cortex or left basal ganglia); a family history of depression; premorbid subcortical atrophy; and premorbid or ongoing social factors. When a patient with a recent stroke meets the criteria for major depressive episode, organic (secondary) mood disorder is diagnosed.

Multiple Sclerosis

Schiffer and Wineman (1990) designed a double-blind placebo controlled study to assess whether desipramine plus psychotherapy would be more effective than placebo plus psychotherapy in the treatment of 28 multiple sclerosis patients who met criteria for major depressive disorder (RDC). Patients were randomized to desipramine or placebo. During the first week of treatment, the desipramine dose was titrated to 150 mg/d or to the maximum tolerable dose. The aim was to obtain serum levels of 125-150 ng/ml. Half of the group treated with desipramine was unable to tolerate doses that would enable them to reach serum levels of 125 ng/ml. However, when the low level group (< 125 ng/ml) was compared to the therapeutic level group (> or = 125 ng/ml), the same number of patients improved within each group, i.e., 6 of 7. According to results of blind clinical judgment 11 of 13 patients in the desipramine group and 6 of 14 patients in the placebo group showed an improvement in their depressive symptoms. This difference in clinical improvement was significant.

Epilepsy

Robertson and Trimble (1985) conducted a double blind controlled study of two antidepressants, nomifensine and amitriptyline compared to placebo in 39 epileptics meeting RDC criteria for depression. At the end of a six-week trial in which the drugs were administered at a fixed dose of 75 mg/d, patients were assessed and there were no significant differences in the clinical improvement among the three groups. It was also noted that there was no significant relationship between serum level and clinical response to antidepressants. This was an important issue because of the possibility of drug-drug interactions occurring between the antidepressants and anticonvulsants. Non-responders at the end of the six-week period had their antidepressant doses doubled and continued the study for another six weeks. At the end of the second 6-week trial, a significant difference between the drugs emerged. Nomifensine was the more effective antidepressant. Despite doubling the dose, there was no correlation between serum levels and therapeutic response. Because of the risk of antidepressant-anticonvulsant interactions it probably reasonable to confine the selection of antidepressants to those known to have a therapeutic blood level. For the tricyclics, a nortriptyline dose producing a therapeutic plasma concentration between 50-150 ng/ml is advisable.

During the treatment of compound depressions it is important to note that conventional dosing and monitoring parameters of antidepressive agents are not always adequate. Though antidepressants are effective in all of the comorbid illnesses discussed, their efficacy is not dependent on adherence to standard treatment protocols. In choosing an antidepressive agent the potential for side effects and how these side effects impact on the comorbid illness must be considered. When treating depression in patients with chronic fatigue syndrome and multiple sclerosis it is best to start at a lower initial dose and increase the dose gradually based on clinical improvement and the appearance of side effects. Patients with seizure disorders may experience an improvement in their depressive symptoms by employing carbamazepine as an anticonvulsant agent. MAOIs and tricyclics have been effective in the treatment of epileptic depressions. When making adjustments in the treatment of depression with comorbid illnesses standard treatments and target blood levels should be de-emphasized and clinical response should be monitored closely.

Dementia/Alzheimer's Disease

Of patients meeting diagnostic criteria for dementia, one-half are afflicted with Alzheimer's Disease. Prevalence of this disease in the United States in 1988 was estimated to be 3 million cases (Pary et al 1990.) Depression is frequently associated with dementia (40%) and with Alzheimer's Disease (25%) (Lazarus et al 1987, Reifler 1988). While much of Alzheimer's research is directed towards reducing or slowing impairment of cognitive function, the significant presence of concurrent major depression and possible treatments could have some impact on the overall progression of the disease.

Pary et al (1990) recommend a antidepressant trials in dementia patients who meet criteria for the diagnosis of depression. Antidepressants whose adverse effect profiles are especially useful in this population are nortriptyline and fluoxetine. Reifler et al (1989) conducted a prospective, double-blind, randomized, placebo-controlled 8-week trial using a parallel design of imipramine in Alzheimer's Disease patients with and without depression. Of the 61 outpatients (mean age = 72, 25 male, 36 female) with primary degenerative dementia of the Alzheimer's type, 28 met the criteria (DSM-III) for major depression. The investigators included non-depressed patients to examine effect on cognitive function in addition to antidepressant effect. Imipramine was slowly titrated upward to a mean dose of 83 mg/d (total imipramine = 119 ng/ml) for the depressed patients and 82 mg/d (total imipramine = 132 ng/ml). A therapeutic imipramine concentration in an adult is usually considered a total concentration of imipramine plus desipramine of greater than 242 ng/ml. It was noted that side effects of drowsiness and dizziness in the depressed versus non-depressed groups were essentially equal. HAM-D ratings of both the depressed and non-depressed patients improved over time with both imipramine and placebo. Two tests of cognitive function (mini-mental state exam and the dementia rating scale) were used to compare depressed versus non-depressed patients and imipramine versus placebo with differing results. Imipramine produced greater improvement on the cognitive measures than placebo regardless of the diagnostic group. It is difficult to judge the significance of this study since the investigators choice of an antidepressant precluded dosing into a therapeutic range due to the adverse effect profile of the drug.

Summary. In patients presenting with signs of both depression and dementia, if symptoms suggestive of dementia are significantly more prominent than depressive symptoms, the diagnosis is dementia with depressive symptoms. If symptoms suggesting a major depressive episode are at least as prominent as those consistent with dementia, the diagnosis is major depressive disorder. In selecting treatment, it is prudent to assume that symptoms suggesting dementia may be manifestations of the depressive disorder until proven otherwise. When the depressive episode ends. so should the symptoms suggestive of dementia. If they do not, the diagnosis of early dementia should be considered.

MAJOR DEPRESSION/MEDICAL ILLNESS TREATMENT STUDIES

Chronic Obstructive Pulmonary Disease

Gordon et al (1985) studied the effects of desipramine on 13 patients with severe chronic COPD in a double blind, crossover study using desipramine and placebo for 8 weeks each. Patients were not diagnostically depressed. However, it was the investigators hypothesis that desipramine would enhance the patients ventilatory drive and improve the arterial blood gases. The desipramine was titrated over 4 weeks to a maximum dose of 100 mg/d. The authors hypothesized that the tricyclic would improve both depression and spirometry scores in these patients. The Beck Depression Inventory (BDI) scale scores showed significant improvement from baseline for both the desipramine and the placebo while the Zung scores showed no significant change following either placebo or desipramine. At baseline the mean ± sd scores were 14 ± 4 for the BDI and 39 ± 9 for the Zung scale. At the end of 8 weeks of desipramine, mean BDI scores were 10 ± 7 (significant improvement, p < 0.05) and mean Zung scales were 36 ± 11 (p = NS). Neither desipramine nor placebo had either a beneficial or adverse effect on the patients' pulmonary function tests which included FEV1, FVC, PaO2, PaCO2 and pH. Thus all the could be concluded from this study is that tricyclic antidepressants are not contraindicated in patients with COPD.

Light et al (1986) contrasted the antidepressant efficacy of six weeks of doxepin (mean = 105 mg/d) to placebo in 12 with severe chronic COPD patients in using a double-blind crossover design. Each treatment was administered for 6 weeks with a 2 week washout period between therapies. Although patients were required to have a score of > 15 on the Beck Depression Inventory and > 50 on the State-Trait Anxiety Inventory, they were not required to meet any diagnostic criteria for depression. There was no significant difference (p < 0.05) in the BDI score when doxepin and placebo therapy were compared. Three of the 12 patients in the study dropped out due to side effects such as drowsiness, blurred vision, and nausea. Pulmonary function tests were not affected either beneficially or detrimentally by doxepin. Neither doxepin nor placebo had either a beneficial or adverse effect on the patients' pulmonary function tests which included FEV1, FVC, PaO2, PaCO2 and pH.

Borson et al (1992) randomly administered nortriptyline 1 mg/kg/d or placebo to 30 COPD for a 12-week treatment trial in the treatment of their depression. All patients had a primary diagnosis of moderate to severe COPD (FEV1 and FEVa/FVC < 60% of predicted and a coexistent diagnosis of depressive disorder. The criteria for diagnosing depressive disorder were not specified. Responders were defined as patients who had a score of 1 or 2 on the Clinical Global Impression, i.e., markedly or moderately improved respectively. Ten (77%) patients responded to nortriptyline in contrast to only 2 receiving placebo (12%) (X2 = 13.0, p < 0.0003). Patients' ratings on the Hamilton Depression Rating Scale (HAM-D) improved by 60% (29.6 ± 7.6 to 12.6 ± 6.9) while placebo improved ratings by 17% (29.5 ± 6.4 to 22.8 ± 11.3) (F = 7.72, df =1, p = 0.01). A 45% reduction in mean score on the Patient Related Anxiety Scale was seen with patients on nortriptyline (54.3 ± 17.0 to 29.9 ± 11.4) while a 4% improvement was seen with patients on a placebo (47.4 ± 21.5 to 45.3 ± 28.6, p < 0.005). Nortriptyline did not affect shortness of breath in day to day activities or during structured exercise. As in the two previous studies the antidepressant had no effect on pulmonary function tests.

Myocardial Infarction

Because of the side effects of tricyclic antidepressants such as conduction disturbances, tachycardia, and orthostatic hypotension, they are contraindicated for the first 6 weeks following a myocardial infarction (Kavan et al 1991, Stern 1985). According to Schleiffer et al (1989), 45% of patient admitted to the hospital for an MI will develop symptoms of major or minor depression within 8-10 days. Since the tricyclic antidepressants and monoamine oxidase inhibitors are contraindicated, the clinical question still remains which antidepressant pharmacologic treatment are acceptable for a post-MI depressed patient. Potential alternative pharmacologic treatments include the benzodiazepine, alprazolam and fluoxetine (Kavan et al 1991). No studies have been found concerning the safety and efficacy of other antidepressants such as fluoxetine or bupropion in the treatment of post-MI depression, but they appear to have minimal significant effects on blood pressure, heart rate, and conduction. ECT, relatively contraindicated in the first three months post-MI, has been used successfully to treat severely depressed patients in the immediate post-MI period.

Summary. The relationship between depression and increased morbidity and mortality is well documented in both post-myocardial infarction patients and in coronary artery disease patients without myocardial infarction. Give the higher morbidity and the fact that most of these patients do not develop a major depression, the practitioner is advised to screen assess fully, and treat major depression when present in these patients groups.

Chronic Fatigue Syndrome

Manu et al. (1989) evaluated 44 patients for depressive disorder (DSM-III-R) secondary to chronic fatigue syndrome. Twenty-four patients were treated with antidepressant medication (19 TCAs, 4 phenelzine, 1 TCA/lithium). Twenty reported significant improvement of their fatigue symptoms and their depressive disorder. The importance of this study is that it confirmed the hypothesis that approximately half the patients with chronic fatigue syndrome are depressed and will have their symptoms improved by antidepressant medication. There are anecdotal reports that in some cases of chronic fatigue syndrome patients poorly tolerate the first generation tricylic antidepressants due to the sedating side effects that may exacerbate fatigue symptoms. However, 7 of the 24 patients were treated with sedating TCAs (doxepin, imipramine, and amitriptyline). Lynch et al. (1991) suggests that sedating TCAs can be tolerated and adverse effects minimized by using lower doses initially and slowly titrating the dosage upward. The antidepressant drug used should be chosen based on the level of fatigue and the level of anxiety. When fatigue is mild but anxiety severe, a more sedating drug such as amitriptyline could be used. When fatigue is severe and anxiety mild, a less sedating drug would be a better choice. In a systematic follow up of 50 patients with chronic fatigue syndrome 30 patients responded to treatment with either lofepramine, a TCA, or fluoxetine (Lynch et al 1991). A third of the responders showed a 50% or greater decrease in the severity of depressive symptoms. Another third showed a 25-50% reduction in symptom severity. Twenty-five of thirty responders discontinued treatment without relapse for a six month period.

Summary. Nearly all depressed patients complain of fatigue and low energy. This symptom is associated with a 46-75% lifetime rate of major depressive disorder. Complaints of chronic fatigue must be differentiated from the formal chronic fatigue syndrome.

Post-Partum Depression

Because post-partum depression affects approximately 10% of all childbearing women (Robinson and Stewart 1986, Butler and Leonard BE 1986), the importance and effects of therapy decisions are far-reaching. Relief from despondency, emotional lability, guilt, anorexia, sleep disorders, feelings of inadequacy, fatigue, and irritability provide the mother, the infant, and their family with a healthier environment. Current literature supports the use of both drug therapy and psychotherapy for post partum depression.

Butler and Leonard (1986) treated eight cases of post-partum depression with nomofensine 150 mg/d. Seven of the eight cases were patients who had experienced depression previously with pregnancy. The patients medical and psychiatric parameters were compared to 8 non-depressed mothers. Treatment and control subjects were matched for age and obstetrical status which included parameters such as postpartum time, number of previous children, and use of anaesthetic during delivery. In addition to assessing efficacy of drug treatment in the depressed group, the study also examined hormonal status in depressed mothers vs. control non-depressed mothers, and biochemical markers of depression in the depressed group. Following six weeks of antidepressant treatment, the HAM-D depression ratings decreased to scores equal to the non-depressed controls. Robinson and Stewart (1986) suggest the use of tricyclic antidepressants at their usual recommended therapeutic doses to alleviate difficulty sleeping and persistent post partum depression. However, they do not document these assertions.

HIV Seropositivity

In a retrospective chart review, Hintz et al (1990) reviewed charts of 90 male outpatients, mean age 37 (21-61) who had been treated with antidepressants. One group of 45 were seropositive for HIV while the second group of 45, matched by sex, age, and treatment criteria, HIV-negative with no known risk factors for the illness. The response rate for antidepressant treatment was contrasted in the two groups. A large percentage of both groups (89% of HIV-positives, 94% of HIV-negatives) met DSM-III-R criteria for an affective disorder, i.e., major depression, dysthymia, schizoaffective, or bipolar depressed. The only other diagnoses included organic mood disorder and adjustment disorder with depressed mood. The HIV-positive group was most commonly treated with either amitriptyline, imipramine, or desipramine while the HIV-negative group were more commonly treated with fluoxetine or trazodone. All the antidepressants appeared to produce a beneficial antidepressant effect in the HIV-positive patients with the exception of trazodone, in whom only subtherapeutic doses of 50-100 mg/d were prescribed. The efficacy of treatment for the HIV negative group was determined to be slightly higher the efficacy for the HIV positive patients, however some treatment response was noted for both groups. It was noted that antidepressant dosages tended to be higher in the HIV-negative patients. Of the HIV positive group, the asymptomatic patients achieved higher efficacy ratings than the AIDS and ARC patients. It was postulated that health factors could alter treatment response and that immune function and CNS alterations common to advanced HIV infection play an interactive role in response to drug therapy of any nature. Not surprisingly, side effect incidence and severity was also greater in the symptomatic group of HIV positive patients. Although the retrospective design of this study limits its usefulness as a therapeutic guide, it does suggest benefit can be derived from antidepressant therapy for HIV seropositive patients who meet criteria for major depression.

REFERENCES

Balunov OA, Sadov, OG, Alemasova AY (1990). Therapy of depressions in post-stroke patients. Alaska Medicine 32:27-9.

Borson S, McDonald GJ, Gayle T, et al (1992). Improvement in mood, physical symptoms, and function with nortriptyline for depression in patients with COPD. Psychosomatics 33:190-201.

Butler J, Leonard BE (1986). Postpartum depression and the effect of nomifensine treatment Int Clin Psychopharmacol. 1:244-52.

Task Force on DSM-IV (Work In Progress 1/8/93). DSM-IV Draft Criteria. American Psychiatric Association, Washington, DC.

Finklestein SP, Weintraub RJ, Davar G, et al (1987). Antidepressant drug treatment for post-stroke depression: Retrospective study. Arch Phys Med Rehabil 68: 772-6.

Gordon GH, Michiels TM, Mahutte CK, et al (1985). Effect of desipramine on control of ventilation and depression scores in patients with severe COPD. Psychiatry Res. 15:25-32.

Hintz S, Kuck J, Peterkin JJ, et al (1990). Depression in the context of Human Immunodeficiency Virus infection: implications for treatment. J Clin Psychiatry 51:497-501.

Kavan MG, Elsasser GN, Hurd RH (1991). Depression after acute myocardial infarction. Post Grad Med 89:83-9.

Keitner GI, Ryan CE, Miller IW et al (1991). 12-Month outcome of patients with major depression and comorbid psychiatric or medical illness (compound depression). Am J Psychiatry 148:345-50.

Lazarus L, Newton N, Cohler B, et al (1987). Frequency and presentation of depressive symptoms in patients with primary degenerative dementia. Am J Psychiatry 144:41-5.

Light RW, Merrill EJ, Despars J, et al (1986). Doxepin treatment of depressed patients with chronic obstructive pulmonary disease. Arch Intern Med 146: 1377-80.

Lingham VR, Lazarus LW, Groves L, et al (1988). Methylphenidate in treating post-stroke depression. J Clin Psychiatry 49: 151-3.

Lipsey JR, Robinson RG, Pearlson GD (1984). Nortriptyline treatment of post-stroke depression: a double-blind study . Lancet 1:297-300.

Lynch S, Seth R, Montgomery S (1991). Antidepressant therapy in the chronic fatigue syndrome. B J Gen Prac 41:339-342.

Manu P, Matthews DA, Lane TJ et al (1989). Depression among patients with a chief complaint of chronic fatigue. J Affective Disord 17:165-172.

Murray GB, Shea V, Conn DK (1986). Electroconvulsive therapy for post-stroke depression. J Clin Psychiatry 47:258-60.

Pary R, Tobias CR, Lippmann S (1990). Dementia: what to do. Southern Medical Journal. 83:1182-88.

Reding MJ, Orto LA, Winter, et al (1986). Antidepressant therapy after stroke. A double-blind trial. Arch Neurol 43:763-5.

Reifler BV (1988). Clinical problems in geriatric psychiatry. NC Med J. 49:536-8.

Reifler BV, Teri L, Raskind M, et al (1989). Double-blind trial of imipramine in Alzheimer's Disease patients with and without depression. Am J Psychiatry. 146:45-9.

Robertson MM, Trimble MR (1985). The treatment of depression in patients with epilepsy a double-blind trial. J Affective Disord 9:127-136.

Robinson GE, Stewart DE (1986). Postpartum psychiatric disorders. Can Med Assoc J. 134:31-7.

Schiffer RB, Wineman NM (1990). Antidepressant pharmacotherapy of depression associated with multiple sclerosis. Am J Psychiatry 147:1493-7.

Schliefer SJ, Macari-Hinson MM, Coyle DA et al (1989). The nature and course of depression following myocardial infarction. Atch Intern Med 149:1785-9.

Stern TA (1985). Management of depression and anxiety following myocardial infarction. Mt. Sinai J Med 52:623-33.

Yates WR, Wesner RB, Thompson R (1991). Organic mood disorder: a valid psychiatry consultation diagnosis? J Affective Disord 22:37-42.

[Prevalence And Characteristics Of Chronic Pain In Veterans With Spinal Cord Injury]

and ?.................

............you put your left foot in..............you put your left foot out.................?????

[Sleepless Nights May Encourage Pain]

Sleepless Nights May Encourage Pain

THURSDAY, April 5 (HealthDay News) -- Poor sleep can raise risks for pain in women, a new study suggests.

"This study finds that fragmented sleep profiles, akin to individuals suffering from middle of the night insomnia, health care workers on call, and parents caring for infants, alter natural systems that regulate and control pain, and can lead to spontaneous painful symptoms," researcher Michael T. Smith, of Johns Hopkins University, said in a prepared statement.

The findings are published in the April 1 issue of the journal Sleep.

The study included 32 healthy women who were studied for seven nights. For the first two nights, the women slept undisturbed for eight hours. For the next few nights, the women were then assigned to one of three groups: a control group that continued to sleep undisturbed; a forced awakening (FA) group awakened once an hour (eight times) through the night; and a restricted sleep opportunity (RSO) group subjected to partial sleep deprivation by delaying their bedtime.

On the sixth night, the women in both the FA and RSO groups underwent 36 hours of total sleep deprivation, followed by an 11-hour recovery sleep.

During the study, researchers tested the women's pain thresholds and pain inhibition. The women in the FA group showed an increase in spontaneous pain, while those in the control and RSO groups showed no changes in spontaneous pain or pain inhibition.

"Our research shows that disrupted sleep, marked by multiple prolonged awakenings, impairs natural pain control mechanisms that are thought to play a key role in the development, maintenance, and exacerbation of chronic pain," Smith said.

-- Robert Preidt

SOURCE: American Academy of Sleep Medicine, news release, April 1, 2007

Copyright © 2007 ScoutNews, LLC. All rights reserved.

SOURCE: http://www.medicinenet.com/script/main/art...rticlekey=80294

[Prevalence And Characteristics Of Chronic Pain In Veterans With Spinal Cord Injury]

Volume 42 Number 5, September/October 2005

Pages 573 — 584

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Prevalence and characteristics of chronic pain in veterans with spinal cord injury

Diana H. Rintala, PhD;* Sally Ann Holmes, MD; Richard Neil Fiess; Daisy Courtade, MA; Paul G. Loubser, MD

Michael E. DeBakey Department of Veterans Affairs Medical Center, Houston, TX; Baylor College of Medicine, Houston, TX

Abstract — To assess prevalence and characteristics of individual chronic (>6 mo) pain components in the veteran spinal cord injury (SCI) population, we conducted a telephone survey with 348 (66%) of 530 veterans with SCI who received care from one regional Department of Veterans Affairs SCI center during a 3 yr period. The short-form McGill Pain Questionnaire was used to assess qualitative properties of the pain experience. Other questions were used to assess frequency, duration, intensity, exacerbating factors, and effects on daily activities. Of the participants, 75% reported at least one chronic pain component. The majority (83%) of the chronic pain components occurred daily (mean = 27.4 d/mo) and lasted most of the day (mean = 17.4 h/d). Mean pain intensity in the week before the interview averaged 6.7 (on a 0 to 10 scale), while worst pain intensity averaged 8.6. Two-thirds (67%) of the chronic pain components interfered with daily activities. The most commonly selected pain descriptors were "aching," "sharp," "hot-burning," and "tiring-exhausting." More research is needed to identify better ways to prevent, assess, and treat chronic pain in the veteran SCI population.

Key words: adult, chronic, female, intractable pain, male, prevalence, spinal cord injury, survey, telephone, veterans.

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Abbreviations: ANOVA = analysis of variance, K-W = Kruskal-Wallis, MEDVAMC = Michael E. DeBakey Department of Veterans Affairs Medical Center, SCI = spinal cord injury, SCI/D = SCI or dysfunction, SD = standard deviation, SF-MPQ = short-form McGill Pain Questionnaire, VA = Department of Veterans Affairs.

This material was based on work supported by the Department of Veterans Affairs, Veterans Health Administration, Rehabilitation Research and Development Service, grant B2573R.

*Address all correspondence to Diana H. Rintala, PhD; MEDVAMC (153), 2002 Holcombe Boulevard, Houston, TX 77030; 713-791-1414, ext. 5807; fax: 713-794-7623. Email: drintala@bcm.tmc.edu

INTRODUCTION

Based on eight studies published between 1985 and 1999 on pain following spinal cord injury (SCI), Siddall and Loeser estimated that 65 percent of persons with SCI experience pain [1]. In six, more recent reports (1998-2003), estimates of the prevalence of pain in persons with SCI ranged from 75 to 81 percent [2-7]. Specifically, 1,135 (77.4%) of the total 1,467 participants experienced pain. Four of the studies used mailed surveys, one used telephone interviews with a research nurse, and one used in-person interviews with an anesthesiologist. Three of the studies were conducted in the United States and one each in Australia, Denmark, and the United Kingdom. Despite these differences in location and method, the reports of prevalence of pain were similar.

While recent studies have reported similar prevalence of pain, the characteristics of pain reported have varied considerably. Time from SCI to pain onset has ranged from immediately after the SCI to 10 or more years postinjury [2,5,8-9]. Time since pain onset has ranged from less than 1 year to more than 10 years [7]. Many persons with SCI experience pain almost everyday, often with little or no break during the day, while others only experience pain periodically [4,8]. Severity of pain has been measured with verbal scales (e.g., mild, moderate, severe) and with numerical scales (e.g., 0 to 10, 0 to 100, 1 to 5). Using verbal scales, 39 percent of the participants in one study [7] and 58 percent in another [2] reported severe pain. On numerical scales, average pain intensity has ranged from 41 to 59 percent of the maximum score (e.g., 41/100, 4.1/10), while pain at its worst has ranged from 72 to 82 percent of the maximum score [4-6,9-10]. The relationship between verbal and numerical rating scales has indicated that ratings of 1 to 4 on either scale correspond to mild pain, 5 to 6 to moderate pain, and 7 to 10 to severe pain [11-12]. Reported exacerbating factors have included muscle spasms, activity, touching the area where the pain occurs, and cold weather [7].

The prevalence of chronic pain specifically in veterans with SCI has not been previously reported. Determination of the prevalence, severity, and characteristics of chronic pain experienced by veterans with SCI who receive healthcare from Department of Veterans Affairs (VA) facilities is important in the planning of services and future research efforts. One cannot assume that findings regarding chronic pain in nonveterans apply to veterans, particularly veterans who receive healthcare from VA facilities. Evidence suggests that veterans are more likely than nonveterans to have psychiatric disorders [13], be homeless [14], smoke [15-16], and drink heavily [17-19]. Furthermore, veterans who receive at least some of their healthcare from a VA facility have been found to be socioeconomically disadvantaged and to have poorer health than veterans who receive all of their healthcare elsewhere [20]. A large study found that elderly men treated for acute myocardial infarction at VA hospitals were more likely to have coexisting conditions, including hypertension, chronic obstructive pulmonary disease or asthma, and diabetes, than comparable Medicare patients treated at non-VA hospitals [21]. Thus, one could argue that the characteristics of chronic pain in veterans with SCI in general and in veterans who seek healthcare from VA facilities in particular differ from those reported in the literature on nonveterans and/or veterans who receive care from non-VA facilities.

To our knowledge, only one other study has been published exclusively on the prevalence and characteristics of chronic pain in U.S. veterans with SCI or dysfunction (SCI/D). Gironda and colleagues found that 81 percent of veterans with paraplegia reported chronic pain in a mailed survey [22].

The current study assessed various facets of chronic pain in veterans with SCI/D at any level of injury who received healthcare from one VA SCI center during a 3-year period. Key questions to be answered included-

1. What is the prevalence of chronic pain in veterans with SCI/D?

2. How long after the onset of SCI/D does chronic pain begin and how long has it been since it began?

3. How frequently does chronic pain occur, how long does it last, and how does it affect daily activities?

4. Are there certain times of day, activities, and/or situations during which chronic pain begins or is at its worst?

5. How severe is chronic pain on average and at its worst?

6. What words describe chronic pain?

7. What areas of the body are affected by chronic pain, and how are those areas related to the level of the SCI/D?

8. How does chronic pain vary depending on its location relative to the level of SCI/D?

METHODS

Sample

Our sampling frame was the 530 veterans with SCI/D who received healthcare during fiscal years 1999 to 2001 at the SCI Center of the Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, Texas. The MEDVAMC SCI Center provides SCI rehabilitation, primary care, and SCI specialty (medical and surgical) healthcare to veterans who are served by the South Central VA Healthcare Network and are residents of southeast Texas, Arkansas, northern Florida, Louisiana, Mississippi, and Oklahoma. From the original sampling frame, 348 veterans (345 men, 3 women) participated. Of the 182 who did not participate, 22 were deceased, 29 refused, and 110 were unable to be located despite our repeated attempts to contact them directly as well as through their identified next of kin. In addition, 21 were unable to participate for a number of reasons (8 had no help using the telephone, 5 had dementia, 3 were unable to speak, 3 were ventilator-dependent and unable to complete the lengthy telephone interview, 1 was comatose, and 1 was out of the country). Women were underrepresented among the participants (participants = 0.9% female [n = 3], nonparticipants = 3.8% female [n = 7], c 2 = 5.75, Fisher's exact test p < 0.04). The participants and nonparticipants did not significantly differ in age, race/ethnicity, or level and completeness of injury. The characteristics of the sample are displayed in Table 1.

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Table 1.

Characteristics of the study sample. Characteristic Value

Age (yr)

Mean ± SD 54.8 ± 11.6

Median 53.9

Range 23-84

Age at Onset (yr)

Mean ± SD 37.3 ± 13.8

Median 34.5

Range 19-77

Time Since Onset (yr)

Mean ± SD 17.5 ± 12.0

Median 16.1

Range 0.3-60.0

Sex, n (%)

Male 345 (99.1)

Female 3 (0.9)

Race/Ethnicity, n (%)

Caucasian 210 (60.3)

African American 122 (35.1)

Hispanic 13 (3.7)

Native American 2 (0.6)

Other (unspecified) 1 (0.3)

Education, n (%)

Less than high school 36 (10.3)

High school or GED 110 (31.6)

Some college or trade school 121 (34.8)

Associate's degree 25 (7.2)

Bachelor's degree or higher 56 (13.1)

Income, n (%)

<$15,000 81 (23.3)

$15,000 to $24,999 59 (17.0)

$25,000 to $49,999 43 (12.4)

≥$50,000 33 (9.5)

Not reported 132 (37.9)

Level and Completeness of Injury, n (%)

High tetraplegia (ASIA A, B, or C) 26 (7.5)

Low tetraplegia (ASIA A, B, or C) 86 (24.7)

Paraplegia (ASIA A, B, or C) 133 (38.2)

All ASIA D and E 95 (27.3)

Not applicable* 8 (2.3)

Etiology,† n (%)

Motor vehicle crash 130 (37.4)

Violence 63 (18.1)

Sports 18 (5.2)

Fall 53 (15.2)

Flying or falling object 8 (2.3)

Other‡ 75 (21.6)

*Includes cervical spondylosis, cauda equina, central cord syndrome, and multiple sclerosis.

†Etiology was missing for one participant.

‡Includes health problems such as abscess, stroke, or meningitis; occurrences such as explosions, aircraft accidents, and surgery; and causes unknown to participant.

ASIA = American Spinal Injury Association (impairment classification A, B, C, D, E), GED = General Educational Development (high school equivalency diploma test), SD = standard deviation.

Procedures

From May 2001 to June 2002, an attempt was made to contact and interview by telephone all 530 veterans in the sampling frame. If potential participants were unreachable by telephone, letters were sent to their last known address asking them to contact the research staff. Once in contact by telephone and prior to data collection, the study was explained, the veteran's questions were answered, and oral consent was obtained if the person wished to participate. A structured interview was conducted, and data were entered directly into the computer with commercially available survey software (SurveyView®, Ville Platte, Louisiana). The interview began during the recruitment telephone call or was scheduled for another time. The interview was conducted in more than one session if the participant became fatigued or could not continue for some other reason. After the survey was completed, checks for $10 were sent to participants reporting no chronic pain and for $25 to participants reporting at least one chronic pain. This payment scheme compensated participants with chronic pain for the longer time needed to answer additional questions about their pain. Prior to completing the survey, participants were told neither the exact amount of payment they would receive nor that the amount depended on whether they had chronic pain. Study procedures were approved by the appropriate institutional review boards and all data were collected in compliance with the standards of these boards.

Measures

Demographic and Injury-Related Data

Information regarding age, sex, race/ethnicity, education, income, age at onset of SCI/D, time since onset of SCI/D, and etiology of SCI/D was obtained during the interview. The level and completeness of SCI/D were obtained from the medical records.

Pain Data

Frequent Pain, Chronic Pain, and Time after Injury to Pain Onset. Participants were asked if they had frequent pain. If so, they were asked how long they had been experiencing their worst pain. A chronic pain component could encompass more than one area of the body if the pain was in all areas at the same time, under the same circumstances, and described as one pain by the participant. Chronic pain was defined by the presence (continuous or intermittent) of an individual pain component for at least 6 months. Participants reported each frequent pain in descending order of severity. Additional questions were asked about each chronic pain component. Participants were asked how long after their SCI/D each chronic pain component began.

Days and Hours with Pain. For each chronic pain component, participants were asked how many days out of the past month they had experienced that pain and, on those days, how many hours on average they experienced the pain.

Perceived Effect of Pain on Daily Activities. Participants were asked whether each chronic pain had interfered with their normal daily activities none, some, or a lot during the past month.

Time of Day Pain Begins and Is Worst. Participants were asked whether each chronic pain component usually began at a certain time of day. If so, they specified morning, afternoon, evening, or night. A similar question was asked regarding the time of day when the chronic pain component was at its worst.

Activity or Situation Related to Beginning of Pain and Pain at Its Worst. For each chronic pain component, participants were asked whether some activity or situation seemed related to when the pain began or was at its worst. If so, they described that activity or situation in their own words (i.e., no checklist was used).

Average Pain Intensity and Pain Intensity at Its Worst. On a scale from 0 (no pain) to 10 (worst possible pain), participants were asked to rate their average chronic pain during the past week. Using the same scale, they were then asked to rate this pain when it was at its worst.

Short-Form McGill Pain Questionnaire. The short-form McGill Pain Questionnaire (SF-MPQ) was used to determine the properties of the pain experience [23]. Participants indicated whether each of 15 words (e.g., "throbbing," "shooting," "hot-burning") described their chronic pain component. If so, they then rated the intensity of that pain quality as 0 (none), 1 (mild), 2 (moderate), or 3 (severe). Two subscale scores (affective and sensory) were computed by separately summing ratings for the four affective words and eleven sensory words. A total score was computed by summing the ratings across all 15 items. Correlation coefficients between the short and long forms of the MPQ range from r = 0.62 to 0.90 [24]. The SF-MPQ has been found to reflect the analgesic effects of drugs administered for labor pains, musculo-skeletal pain, and postsurgical pain.

Area of Body Affected and Relation to Level of Injury

Participants were asked to describe in their own words the area(s) of the body in which each chronic pain component occurred. These descriptions were then grouped into six mutually exclusive categories:

1. All or most of body: Pain extends down from the neck or upper trunk and involves at least one lower limb, or pain does not occur in the neck or upper trunk but involves at least one upper and one lower limb.

2. Trunk: Pain includes part of the trunk and may include the head and neck but does not involve any limbs or only the back.

3. Upper limbs: Pain includes at least one upper limb and may include the upper back and neck but no other part of the trunk.

4. Back only: Pain does not involve any area of the body except for the back.

5. Lower body: Pain extends down from the waist (no higher) and involves some lower limbs.

6. Lower limbs only: Pain includes at least one lower limb and no other area of the body.

One of the physician investigators later determined the relation of the area(s) of pain to the level of injury and categorized the relations as above level only; above and at level; above, at, and below level; at level only; at and below level; or below level only.

Data Analysis

Descriptive statistics, including mean, median, standard deviation (SD), and range for continuous variables, and number and percentage for categorical variables, were obtained for each study variable. Subscale (affective and sensory) and total scores were computed for the SF-MPQ. The distribution of the area(s) where pain occurred relative to the level of injury was obtained for the entire sample of chronic pain components, as well as separately for participants with tetraplegia and paraplegia. The difference was assessed with a chi-square analysis.

Kruskal-Wallis (K-W) one-way analysis of variance (ANOVA) was performed to identify associations between the pain-related continuous study variables and-

1. Time after SCI/D to onset of pain, recoded into early (<1 year), middle (1 to 10 years), and late (>10 years) onset.

2. Duration of pain, recoded into 6 months to 5 years, >5 years to 15 years, and >15 years.

3. Area(s) of the body affected by pain relative to the level of the SCI/D.

Nonparametric K-W analyses were selected because several study variables were not normally distributed. Chi-square analysis was performed to identify associations of the three variables (time-to-onset, duration, area of body) with each other, as well as with the 15 SF-MPQ descriptive words, regardless of intensity (i.e., selected versus not selected). The associations of the three-category time-to-onset and duration variables with area of the body affected by pain were also assessed with chi-square analyses.

RESULTS

Eighty-one percent (283/348) of the participants reported at least one frequent pain component. Eighteen of these participants reported pain components that had lasted less than 6 months and therefore did not meet the criteria of chronic pain. Thus, 76 percent (265/348) of the participants reported at least one chronic pain component. These 265 participants reported a total of 300 chronic pain components, an average of 1.1 components per person. Specifically, 229 participants (86%) reported one chronic pain component, 32 (12%) two components, and 4 (2%) three components.

The distribution of the time from the SCI/D to the onset of the chronic pain component is displayed in Figure 1. These data were recoded into three categories:

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1. Early Onset: <1 year (35% of chronic pain components).

2. Middle Onset: 1 to 10 years (28% of chronic pain components).

3. Late Onset: >10 years (37% of chronic pain components).

This three-category code was examined for relationships with other study variables. The only significant relationships identified were with the SF-MPQ descriptors "stabbing" and "cramping." For middle-onset chronic pain components, "stabbing" and "cramping" were more likely to be selected than for early- or late-onset components ("stabbing": early = 41%, middle = 63%, late = 55%, c 2 = 9.19, p = 0.01; "cramping": early = 33%, middle = 57%, late = 41%, c 2 = 10.49, p = 0.005). Time from injury to onset of pain was not related to days with pain in the past month, hours with pain per day, average or worst pain intensity, the total or subscale scores of the SF-MPQ, area of the body with pain, area of pain relative to the level of injury, or the other 13 descriptors from the SF-MPQ.

The distribution of the duration of the chronic pain components is presented in Figure 2. Duration of pain was significantly related to area(s) of the body in which pain occurred (c 2 = 19.38, p = 0.036). Notably, pains occurring only in the lower limbs and only in the back were more common as duration increased, while pains occurring in the upper limbs and trunk were less common as duration increased. Duration of pain was also significantly related to the SF-MPQ descriptor "fearful," indicating that chronic pain components that had been experienced for a longer time were less likely to be described as "fearful" (6 months to 5 years = 26% of chronic pain components, >5 to 15 years = 19%, >15 years = 13%, c 2 = 6.08, p = 0.048).

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During the past 30 days, 83 percent of chronic pain components were experienced every day (mean = 27.4 days, median = 30.0, range = 1-30) and on days when pain occurred, 60 percent of the chronic pain components lasted 24 hours (mean = 17.4 hours, median = 24, range = 1-24). The majority (67%) of the chronic pain components were reported to interfere with daily activities. Of the 300 chronic pain components, 38 percent were reported to interfere a lot with daily activities and 29 percent somewhat. Nineteen percent (57/300) of the chronic pain components usually began at a particular time of day: 74 percent (42/57) in the morning, 3 percent (2/57) in the afternoon, 14 percent (8/57) in the evening, and 9 percent (5/57) at night. One-third (100/300) of the chronic pain components were at their worst at a particular time of day: 28 percent (28/100) in the morning, 11 percent (11/100) in the afternoon, 37 percent (37/100) in the evening, 23 percent (23/100) at night, and 1 percent (1/100) in both the morning and afternoon. Of the chronic pain components, 59 percent (178/300) began or were at their worst in relation to one or more activities or situations; 215 activities or situations were reported:1 39 percent moving or being active (83/215), 15 percent not moving for a while (32/215), 10 percent sitting or lying in certain positions (21/215), 18 percent particular types of weather or changes in the weather (38/215), and 19 percent miscellaneous (e.g., bowel and bladder issues, being touched, and stress; 41/215).

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1 Percentages sum to 101% due to rounding.

On a scale from 0 to 10, the mean pain intensity for the past week was in the high-moderate to severe range (mean = 6.7 ± 2.2 SD, median = 7.0, range = 1-10, Figure 3) as defined by Jensen et al. [12], while the mean intensity rating when the pain was at its worst was in the severe range (mean = 8.6 ± 1.8 SD, median = 9.0, range = 3-10, Figure 4). The distributions of these ratings were skewed such that higher ratings were more likely than lower ones, particularly for pain at its worst.

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The mean total score on the SF-MPQ was 17.0 ± 10.2 SD (median = 15, range = 0-45). The mean score was 3.4 ± 3.5 SD on the affective subscale (median = 2, range = 0-12) and 13.6 ± 7.6 SD on the sensory subscale (median = 13, range = 0-33). The most frequently selected descriptors of reported chronic pain components, irrespective of intensity ratings, were "aching," "sharp," "hot-burning," and "tiring-exhausting" (Figure 5). The same four words had the highest mean scores on the 0 to 3 intensity scale (i.e., none to severe) (Figure 6). Least likely to be reported as severe were "fearful" (9%), "sickening" (10%), and "gnawing" (11%).

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The chronic pain components were distributed approximately equally across the six derived categories for area(s) of the body in which pain occurred (Figure 7). The majority (232/300, 77%) of the chronic pain components occurred at and/or below the level of the SCI/D lesion (i.e., the sum of "below level only," "at level only," and "at and below level" in Figure 8). The area of pain relative to the level of injury could not be determined for 17 (5.7%) of the chronic pain components based on the survey data. For example, if a participant with a thoracic injury stated that the pain was in his back without specifying lower, middle, or upper back, whether the pain was above, at, below the level of injury, or some combination of those areas was indeterminable.

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Figure 8.

Distribution of body area(s) affected by chronic pain componentsrelative to level of spinal cord injury or dysfunction.

Areas derived from participants descriptions of pain.

The body areas affected by pain relative to level of injury differed significantly between participants with tetraplegia and paraplegia (c 2 = 27.85, p < 0.001, Figure 9). Participants with tetraplegia were more likely to have pain below the level of injury and less likely to have pain above the level of injury. Pain at the level of injury was equally likely.

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K-W ANOVAs, in which the 17 undetermined chronic pain components were excluded, indicated that, based on the body area in which pain occurred relative to the level of injury, there were significant differences in hours with pain on days with pain (K-W c 2 = 13.2, p < 0.03), average pain intensity in the past week (K-W c 2 = 15.0, p < 0.01), and pain intensity when pain was at its worst (K-W c 2 = 11.6, p < 0.04). A trend was also seen for the total SF-MPQ score (K-W c 2 = 9.5, p < 0.10). These analyses indicated that pains simultaneously occurring in all three areas (above, at, and below the level of injury) had the highest rank in all pain measures except average pain intensity in which it had the second-highest rank (Table 2). Pains that occurred both at and below the level of injury were ranked second highest overall. Pains that occurred above and at the level of injury were ranked lowest overall.

Table 2.

Areas of body in which chronic pain occurs relative to level of spinal cord injury or dysfunction by selected pain measures. Areas derived from participants' descriptions of pain. Pain Measure Above, At,

and Below At and Below Above Only Below Only At Only Above and At

Days with Pain* 1 (155) 2 (147) 4 (130) 3 (143) 5 (127) 6 (126)

Hours with Pain* 1 (169) 2 (159) 6 (120) 5 (130) 4 (131) 3 (155)

Average Pain Intensity* 2 (154) 1 (164) 6 (101) 5 (130) 4 (133) 3 (149)

Worst Pain Intensity* 1 (188) 2 (154) 6 (123) 3 (134) 5 (129) 4 (130)

SF-MPQ Total* 1 (175) 3 (153) 2 (153) 4 (128) 5 (128) 6 (123)

SF-MPQ Affective Scale* 1 (175) 2 (154) 3 (151) 5 (130) 4 (131) 6 (120)

SF-MPQ Sensory Scale* 1 (165) 3 (149) 2 (151) 5 (132) 4 (134) 6 (125)

All Pain Measures† 1.14 2.14 4.14 4.29 4.43 4.86

*Order (mean rank).

†Average order.

SF-MPQ = short-form McGill Pain Questionnaire.

Chi-square analyses indicated that the body area in which the chronic pain component occurred relative to the level of injury was significantly related to two descriptors from the SF-MPQ: "shooting" (c 2 = 16.45, p = 0.006) and "hot-burning" (c 2 = 13.75, p = 0.017) (Figure 10). "Shooting" was selected for all but one chronic pain component that occurred in all three areas of the body relative to the level of injury (above, at, and below). "Hot-burning" was selected most frequently for chronic pain components that occurred both at and below injury.

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DISCUSSION

Prevalence of Chronic Pain

This study is unique because it focused exclusively on the prevalence and characteristics of chronic pain in veterans with SCI/D (regardless of level of injury) who received care from a VA healthcare facility. The findings are important because the VA needs accurate information regarding health problems specific to the large SCI/D population that it serves. The prevalence of chronic pain (>6 months) was 76 percent, which is within the range of 75 to 81 percent reported across six recent studies [2-7]. This similarity is somewhat surprising because in those six studies the average participant age ranged from 37 to 43 years compared with 55 years in our study, the average time since onset of SCI/D ranged from 5 to 13 years compared with 18 years in our study, and all but one study included 18 to 30 percent women compared with 1 percent in our study. The differences in sex distribution possibly offset the differences in age and time since injury because women with SCI/D are more likely to report having pain [25], while younger persons with SCI/D [26-27] and persons with SCI/D between 5 and 20 years postinjury [28] are less likely to report having pain.

Onset and Duration of Chronic Pain

More than one-third of the chronic pain components began in the first year following SCI/D, with the majority beginning in the first month. On the other hand, more than one-third of the chronic pain components also began 10 years or more following SCI/D. This large range of time from SCI/D to pain onset is similar to Barrett et al.'s study in which 47 percent of pains began in the first year after SCI/D and 27 percent began 10 or more years after SCI/D [9].

Ravenscroft et al. reported that 18 percent of their sample had experienced chronic pain for more than 10 years [7]. In our study, 57 percent had experienced chronic pain for more than 10 years. In part, the difference in duration of pain may be a function of the maximum time since injury for study participants, which was 38 years in the Ravenscroft et al. study and 60 years in our study.

Severity of Pain

The average severity rating of pain during the past week reported by our sample (67% of maximum score) was higher than mean pain severity rating in other studies (range of 41% to 59% [4-6,8-9]). Similarly, the severity rating when the pain was at its worst was somewhat higher in our sample (86% of maximum score) than in other studies in which only a minority of participants were veterans (73% and 83% [6,8]).

In short, our veteran sample was just as likely to have chronic pain as several nonveteran samples with SCI; however, the veterans' average and worst pains were more likely to be severe. Most chronic pain components occurred nearly everyday for many hours and interfered in daily activities. The association between chronic pain and a poorer quality of life is well documented [29-31], and two-thirds of the veteran sample reported that pain interfered with daily activities. Chronic pain can incur considerable healthcare costs due to increased use of healthcare facilities and services as well as the cost of medication and other pain treatments [32-33]. Furthermore, chronic pain may reduce or prohibit participation in productive activities [31-32].

Limitations of the study include the very small number of women and their underrepresentation relative to the sampling frame, the nonparticipation of one-third of the sampling frame, and the use of data self-reported in a telephone survey. Nevertheless, the sample was reasonably large and, with the exception of sex, the participants and nonparticipants did not differ significantly on the available demographic and injury-related data.

Despite obtaining large amounts of information on chronic pain in our sample of veterans with SCI/D, we were unable to classify the pains by type (e.g., neuropathic, musculoskeletal, visceral) based solely on the survey data. Because the survey was done over the telephone, we were unable to indicate the area(s) of chronic pain on body diagrams as is commonly done during in-person interviews or with mailed surveys. Furthermore, if a participant reported leg pain, for example, we did not ask whether the pain was in one or both legs. Thus, diffuse pain (a characteristic of neuropathic pain) was difficult to determine. In some cases (5.7%), the relationship of the area of the pain relative to the level of injury (an important factor in classification of neuropathic pain) was impossible to determine. In 2002, Cardenas et al. described a classification scheme that accounts for the location of the pain relative to the level of injury by use of (1) shaded portions of a body diagram, (2) level and completeness of injury, and (3) participant self-reports of the effects of activity, position, and light touch on the pain; source of pain (musculoskeletal or nervous system); and exacerbating factors [34]. Unfortunately, our survey instrument was developed and our data collected before their study was published, so we could not benefit from their methodology. In future telephone surveys of chronic pain, participants who reported having chronic pain could be sent a body diagram to complete for each reported chronic pain component. They could be asked to shade in the areas of the body affected by each chronic pain component and then return the diagram by mail.

CONCLUSIONS

The VA provides healthcare to 15,000 veterans with SCI each year [35]. Extrapolating from our finding that 76 percent of veterans with SCI/D have chronic pain, we estimate that 11,400 veterans with SCI/D who receive care from the VA have chronic pain requiring assessment and ongoing treatment and 6,270 have severe chronic pain (i.e., intensity rating of Š7 on a 0 to 10 scale) on average during the week [12]. Furthermore, based on our finding that half of the veterans with SCI/D were injured more than 16 years ago and half were over the age of 53 at the time of our study, the prevalence of chronic pain is likely to increase in the national veteran SCI/D population due to aging and increasing time since injury. Policy and program planners need to be aware of the high prevalence and severity of chronic pain among veterans with SCI/D who receive healthcare at VA facilities.

We anticipate publishing future papers based on additional information obtained during our study, including the relation of chronic pain to-

1. Demographic data.

2. Injury-related data.

3. Activities and participation.

4. Environmental factors.

5. Psychosocial factors.

6. Reported treatments and their perceived effectiveness.

7. Satisfaction with the pain-related care received from healthcare professionals.

The findings of this study suggest that more research is needed to further determine modifiable risk factors for chronic pain (e.g., overuse syndrome) and causes of chronic pain (e.g., poor posture, neuropathic abnormalities). Better assessment (e.g., improved assessment tools, regular monitoring of chronic issues) and better treatment (e.g., more effective medications, procedures, self-management techniques) of chronic pain in veterans with SCI/D are also indicated. The need for such research fits well with the current emphasis on evidence-based medicine [36].

ACKNOWLEDGMENTS

Dr. Loubser is now with the Department of Anesthesia, Champlain Valley Physicians Hospital Medical Center, Plattsburgh, New York. We gratefully acknowledge the contributions of Rebeca Matamoros, Jacquie Frnka, and Bonnie Sandoval in conducting this study.

REFERENCES

1. Siddall PJ, Loeser JD. Pain following spinal cord injury. Spinal Cord. 2001;39(2):63-73.

2. Siddall PJ, McClelland JM, Rutkowski SB, Cousins MJ. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain. 2003;103(3):249-57.

3. Widerström-Noga EG, Felipe-Cuervo E, Broton JG, Duncan RC, Yezierski RP. Perceived difficulty in dealing with consequences of spinal cord injury. Arch Phys Med Rehabil. 1999;80(5):580-86.

4. Turner JA, Cardenas DD, Warms CA, McClellan CB. Chronic pain associated with spinal cord injuries: a community survey. Arch Phys Med Rehabil. 2001;82(4):501-9.

5. Finnerup NB, Johannesen IL, Sindrup SH, Bach FW, Jensen TS. Pain and dysesthesia in patients with spinal cord injury: a postal survey. Spinal Cord. 2001;39(5):256-62.

6. Rintala DH, Loubser PG, Castro J, Hart KA, Fuhrer MJ. Chronic pain in a community-based sample of men with spinal cord injury: prevalence, severity, and relationship with impairment, disability, handicap, and subjective well-being. Arch Phys Med Rehabil. 1998;79(6):604-14.

7. Ravenscroft A, Ahmed YS, Burnside IG. Chronic pain after SCI. A patient survey. Spinal Cord. 2000;38(10):611-14.

8. Widerström-Noga EG, Felipe-Cuervo E, Yezierski RP. Relationships among clinical characteristics of chronic pain after spinal cord injury. Arch Phys Med Rehabil. 2001; 82(9):1191-97.

9. Barrett H, McClelland JM, Rutkowski SB, Siddall PJ. Pain characteristics in patients admitted to hospital with complications after spinal cord injury. Arch Phys Med Rehabil. 2003;84(6):789-95.

10. Widerström-Noga EG, Felipe-Cuervo E, Yezierski RP. Chronic pain after spinal injury: interference with sleep and daily activities. Arch Phys Med Rehabil. 2001;82(11): 1571-77.

11. Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain. 1995;61(2):277-84.

12. Jensen MP, Smith DG, Ehde DM, Robinson LR. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain. 2001;91(3):317-22.

13. Norquist GS, Hough RL, Golding JM, Escobar JI. Psychiatric disorder in male veterans and nonveterans. J Nerv Ment Dis. 1990;178(5):328-35.

14. Rosenheck R, Frisman L, Chung AM. The proportion of veterans among homeless men. Am J Public Health. 1994; 84(3):466-69.

15. McKinney WP, McIntire DD, Carmody TJ, Joseph A. Comparing the smoking behavior of veterans and nonveterans. Public Health Rep. 1997;112(3):212-17; discussion 218.

16. Klevens RM, Giovino GA, Peddicord JP, Nelson DE, Mowery P, Grummer-Strawn L. The association between veteran status and cigarette-smoking behaviors. Am J Prev Med. 1995;11(4):245-50.

17. Richards MS, Goldberg J, Rodin MB, Anderson RJ. Alcohol consumption and problem drinking in white male veterans and nonveterans. Am J Public Health. 1989;79(8):1011-15.

18. Richards MS, Goldberg J, Anderson RJ, Rodin MB. Alcohol consumption and problem drinking in Vietnam era veterans and nonveterans. J Stud Alcohol. 1990;51(5):396-402.

19. Winkleby MA, Fleshin D. Physical, addictive, and psychiatric disorders among homeless veterans and nonveterans. Public Health Rep. 1993;108(1):30-36.

20. Koepsell T, Reiber G, Simmons KW. Behavioral risk factors and use of preventive services among veterans in Washington State. Prev Med. 2002;35(6):557-62.

21. Petersen LA, Normand SL, Daley J, McNeil BJ. Outcome of myocardial infarction in Veterans Health Administration patients as compared with Medicare patients. N Engl J Med. 2000;343(26):1934-41.

22. Gironda RJ, Clark ME, Neugaard B, Nelson A. Upper limb pain in a national sample of veterans with paraplegia. J Spinal Cord Med. 2004;27(2):120-27.

23. Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987;30(2):191-97.

24. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975;1(3):277-99.

25. Rintala DH, Hart KA, Fuhrer MJ. Self-reported pain in persons with chronic spinal cord injury. J Am Paraplegia Soc. 1991;14(2):83.

26. Richards JS, Meredith RL, Nepomuceno C, Fine PR, Bennett G. Psycho-social aspects of chronic pain in spinal cord injury. Pain. 1980;8(3):355-66.

27. Fenollosa P, Pallares J, Cervera J, Pelegrin F, Inigo V, Giner M, Forner V. Chronic pain in the spinal cord injured: statistical approach and pharmacological treatment. Paraplegia. 1993;31(11):722-29.

28. Sie IH, Waters RL, Adkins RH, Gellman H. Upper extremity pain in the postrehabilitation spinal cord injured patient. Arch Phys Med Rehabil. 1992;73(1):44-48.

29. American Pain Society [homepage on the Internet]. Glenview (IL): American Pain Society; c1996-2005 [updated 2005 Nov 11; cited 2003 Dec 15]. Chronic pain in America: roadblocks to relief [about 4 screens]. Available from: http://www.ampainsoc.org/whatsnew/conclude_road.htm

30. National Pharmaceutical Council. Pain: current understanding of assessment, management, and treatments. Reston (VA): National Pharmaceutical Council; 2001.

31. White KP, Harth M. The occurrence and impact of generalized pain. Baillieres Best Pract Res Clin Rheumatol. 1999; 13(3):379-89.

32. Kumar K, Malik S, Demeria D. Treatment of chronic pain with spinal cord stimulation versus alternative therapies: cost-effectiveness analysis. Neurosurgery. 2002;51(1):106-15.

33. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the "top 10" physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45(1):5-14.

34. Cardenas DD, Turner JA, Warms CA, Marshall HM. Classification of chronic pain associated with spinal cord injuries. Arch Phys Med Rehabil. 2002;83(12):1708-14.

35. Department of Veterans Affairs Office of Public Affairs [homepage on the Internet]. Washington (DC): Department of Veterans Affairs; c2002 [updated 2002 Feb 22; cited 2002 Jan 4]. VA and spinal cord injury fact sheet [about 1 screen]. Available from: http://www.va.gov/pressrel/spinalcfs.htm

36. Jadad A, O'Brien MA, Wingerchuk D, Angle P, Biagi H, Denkers M. Management of chronic central neuropathic pain following traumatic spinal cord injury. Evidence Report/Technology Assessment Number 45. (Prepared by McMaster University Evidence-Based Practice Center under Contract No. 290-97-0017.) AHRQ Publication No. 01-E063. Rockville (MD): Agency for Healthcare Research and Quality; 2001.

Submitted for publication February 2, 2005. Accepted in revised form May 26, 2005.

DOI: 10.1682/JRRD.2005.02.0033

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Last Reviewed or Updated Thursday, March 23, 2006 7:31 AM

SOURCE:

http://www.rehab.research.va.gov/jour/05/42/5/rintala.html

[3.13 Reasons And Bases]

3.13 REASONS FOR DECISION

a. General. Support conclusions with the necessary level of analysis and explanation. For example, where service connection is being granted, state or discuss the

• benefit being granted,

• basis for the grant, focusing on the in-service event and/or subsequent developments that link the condition to service,

• basis for the evaluation,

• requirements for the next higher evaluation, and

• basis for the effective date.

(1) Grants of service connection must include an explanation or analysis that shows how the entitlement or disability was determined to be service-connected. Computer-generated paragraphs standing alone or conclusory statements without explanation do not satisfy the requirement to state the basis for the grant. See Training Letter

02-02 dated June 19, 2002.

(2) When assigning a disability evaluation, it is not enough to simply list the criteria for the evaluation followed by a statement that a particular evaluation is assigned because the disability meets the criteria. Instead, relate what the evidence shows to the criteria assigned. For example, when explaining the reasons for assigning a thirty percent evaluation to a knee disability state, “You meet the criteria for a thirty percent evaluation because at your examination, severe instability was found in your left knee,” rather than, “Thirty percent is assigned because your disability meets the above criteria.”

b. Review of Evidence. Concisely cite and evaluate all evidence that is relevant and necessary to the determination. Rating decisions must evaluate all the evidence, including oral testimony given under oath and certified statements submitted by claimants, and must clearly explain why that evidence is found to be persuasive or unpersuasive. Decisions must address all pertinent evidence and all of the claimant's contentions. Do not quote at length from letters, affidavits, hospital reports, etc.

c. Next Higher Evaluations. When assigning a disability evaluation, if a higher evaluation is possible under a particular diagnostic code, discuss the criteria for the next higher evaluation. If the reason the veteran does not meet the requirements for the next higher evaluation is not readily apparent, be sure to explain why. Confine the explanation of the criteria for the assigned and next higher evaluations to the diagnostic code under which the disability is evaluated. In the case of hearing loss or visual impairment, a general statement such as “higher evaluations are assigned for greater loss of hearing (or vision)” will be sufficient.

(1) If service connection is granted, do not relate all the details of treatment in service. A simple statement that the enlistment exam was negative and that beginning on a particular date prior to separation the veteran was treated for whatever condition was diagnosed is usually sufficient. The next entry in the paragraph should be the findings from the current exam or a citation of whatever evidence is necessary to establish chronicity and continuity. If the cause of several claimed disabilities is the same, such as one accident, information concerning the origin need only be discussed in detail once in the reasons and bases paragraph for the first disability of common origin.

(2) When granting service connection, extensive discussion of post service treatment is only necessary if essential to the evaluation.

(3) Cite evidence, both favorable and unfavorable, without partiality, especially when a decreased benefit is under consideration. Compare relevant findings at the time of previous rating with present findings.

3-II-4

September 23, 2004 M21-1, Part VI

Change 118

d. Medical Conclusions. Cite medical information and reasoning linking or separating two disabilities or establishing or refuting prior inception or aggravation. Medical conclusions must be supported by evidence in the claims file. Rating Veteran Service Representatives (RVSRs) cannot refute medical evidence submitted by the claimant with their own medical opinions. Rating decisions can cite recognized medical treatises or an independent medical opinion to support a conclusion. Such authority, when relied upon, must be identified in the decision.

SOURCE: http://www.warms.vba.va.gov/Admin21/M21_1/PART6/CH03.DOC

********************************************************************

M21-1, Part VI Veterans Benefits Administration

Change 125 Department of Veterans Affairs

April 19, 2005 Washington, DC 20420

Paragraph 7.24l is updated to change the phrase “Reasons and Bases” to “Reasons for Decision” and the term “rating specialist” to “rating veterans service representative (RVSR).”

SOURCE: http://www.warms.vba.va.gov/Admin21/M21_1/PART6/TRANS.DOC

[3.13 Reasons And Bases]

Paragraph 3.13 has been changed from Reasons & Basis, to “Reasons for Decision”

See below...............

allan

***************************************************

Veterans Benefits Administration M21-1, Part VI

Department of Veterans Affairs Change 100

Washington, DC 20420 February 13, 2003

Veterans Benefits Manual M21-1, Part VI, "Rating Board Procedures," is changed as follows:

Pages 3-i through 3-II-13: Remove these pages and substitute with pages 3-i through 3-II-13, attached.

The entire chapter has been updated to incorporate “RBA 2000,” remove references to “well-grounded” and the Special Issues Rating System (SIRS) which is no longer in use.

Paragraph 3.13 has been changed to “Reasons for Decision” and paragraphs 3.13a and b are updated. Other minor formatting and editorial changes have also been made.

Rescission: M21-1, Part VI, Change 69, dated May 14, 1999.

By Direction of the Under Secretary for Benefits

Ronald J. Henke

Director, Compensation and Pension Service

Distribution: RPC: 2068

FD: EX: ASO and AR (included in RPC 2068)

SOURCE:

http://www.warms.vba.va.gov/Admin21/M21_1/PART6/chg100.doc

[3.13 Reasons And Bases]

Sorry Ricky,

it was recended in 2003. Will pull the info up for you & delete this out of my folders so I don't post it again.

[Insult To Injury]

My gut feeling?

I think they're getting stiffed, just like the rest of us.

These numbers are proof.

I don't suppose Senators like Obama come & hang out at hadit.com? or do they?

No criminal acts? nothing illegal?

Congress & the President need to deal with this now. If treating our wounded like this is not a crime, its time to make it one.

We need mandatory funding for veterans & protection rights making it a federal crime to treat Veterans in such a manor.

Some of these folks need to get the message once & for all, that Mentally, emotionally & physically disable US Veterans, will no longer be "EASY PRAY" for our enemies, foreign or DOMESTIC.

No private, or public agency should be allowed to shirk their responsibility to treat us with respect & dignity, or deny "due process of the law".

One heck of a job, Nickelson.

[Insult To Injury]

My gut feeling?

I think their getting stiffed, just like the rest of us.

These numbers are proof.

I don't suppose Senators like Obama come & hang out at hadit.com? or do they?

No criminal acts? nothing illegal?

Congress & the President need to deal with this now. If treating our wounded like this is not a crime, its time to make it one.

We need mandatory funding for veterans & protection rights making it a federal crime to treat Veterans in such a manor.

Some of these folks need to get the message once & for all, that Mentally, emotionally & physically disable US Veterans, will no longer be "EASY PRAY" for our enemies, foreign or DOMESTIC.

No private, or public agency should be allowed to shirk their responsibility to treat us with respect & dignity, or to provide "due process of the law".

One heck of a job, Nickelson.

[Types Of Painful Conditions]

San Francisco Medical Clinic for the Treatment of Pain

What Types of Painful Conditions Do We Treat

Pain Resulting from Injuries:

Injuries can occur suddenly in car accidents, slips and falls, sports; or they can occur gradually over a period of weeks, months, or even years from repetitive strain at the workplace. Let's discuss various types of pain resulting from injuries.

I. Pain resulting from car accidents:

With automobile accidents, the extent of injury is not usually appreciated at the time of the accident. Although pain is usually felt right away after laceration or direct impact on the body, the pain from muscle sprain and strain may not occur immediately but may intensify into much more acute pain and muscle spasms hours or days later. Whiplash injury and back sprain, which often result from rear end collisions, are prime examples. The victim may initially feel no symptoms or only minor aches but this is often followed by a tired sensation in the involved muscles which subsequently gives rise to spasms and pain. Other unpleasant sensations, normally not described by patients as pain, such as numbness, tingling, and weakness may follow. Pain is a physiological phenomena, not a mechanical one. When a bottle is broken the result can be easily observed; but when a muscle is torn or pulled, the brain does not always respond immediately and may change its reaction with time. Sometimes, the pain may radiate to different parts of the body that have not been injured. For example, a shoulder sprain may produce pain down one's arm along with tingling and numbness in the hand without those parts actually being injured. The pain may also move from place to place during the course of time since pain is a dynamic rather than a static process.

II. It is critical to treat the pain as soon as possible:

The longer the pain resulting from a car accident lingers, the more likely the pain will become chronic. During an acute injury, a pain circuit is activated and set up within the central nervous system, and if it is not quickly diffused, the pain circuit may persist because the brain seems to memorize its function. So the longer it becomes ingrained, the more difficult it is to get rid of it. It has been well documented that herpes zoster (shingles), painful blisters caused by viral infection of a nerve, can become chronically painful long after the skin has healed. This chronic painful phase is known as post-hepatic neuralgia which literally means nerve pain after blisters and can last for years. However, it has been found that if nerve blocks are used to control the pain during the acute phase, the incidence of chronic pain is markedly reduced. The old addage that time will heal all wounds is simply incorrect. In fact, time may seal all pain. Time allows pain to fester, therefore, waiting for the pain to go away after a car accident is not a good idea. A variety of therapeutic modalities are available to alleviate pain and not all of them are equally effective. Some may not change the long-term outlook of the chronic pain. For example, pain medications are used mainly to suppress the pain without causing the body to get rid of it.

III. Other non-painful medical conditions that may result in car accidents:

While chronic pain is the most common symptom following injury in an auto accident, it is by no means the only one. Many injured individuals complain of dizziness and ringing in the ear associated with headaches even though there has been no direct trauma to the head. These symptoms are usually associated with neck injury including sprains and strains. Others may complain of nausea and vomitting and other gastrointestinal symptoms. Women often find their menstrual cycle and flow disturbed subsequent to the accident. While the exact physiological mechanisms causing the symptoms are unknown, they are commonly recognized as stress related. Other symptoms and complexes include a peak of depression, insomnia, nightmares, and an exaggerated fear which may be general but usually specifically related to driving or riding in a car. Such a group of symptoms is quite similar to the post-traumatic stress syndrome that is often found in soldiers after exposure to combat. It appears that the body's alarm system goes off in the face of danger whether it is a combat situation or a car accident. And once such a system is activated, it remains so either indefinitely or for a protracted period of time, even if the danger is long past.

IV. How can the physical and psychological injuries be treated?:

Many treatments are currently available for treating injuries resulting from car accidents and have varying degrees of efficacy. Following is a list of commonly used therapeutic modalities. The list is by no means exhaustive.

1. Physical therapies which include hot and cold packs, electrical stimulation, massages, ultrasound, and infrared treatments.

2. Trigger point injections.

3. Nerve blocks

4. Auriculoneural therapy

5. Acupuncture

6. Osteopathic or Chiropractic manipulation

7. Biofeedback

8. Hypnosis

9. Therapeutic Exercises

10. Traction

V. How to pay for the treatments for car accident injuries:

1. Car insurance: Most car insurance policies cover medical expenses incurred as a result of automobile related injuries with varying dollar limits. This is like a health insurance policy specifically related to auto injury regardless of whether the injured is at fault or not. A person who does not own his individual policy may also be covered by a policy of a member of the same household. For instance, a teenager hit by a car while crossing the street (an auto related injury) may be covered by the insurance policy of his older brother with whom he lives.

2. Health insurance: Health insurance usually covers the treatment expenses but it is generally a good idea to check with one's own insurance company to see what services are covered before treatment. If you belong to a HMO health plan, it is quite possible that you will be covered only if you see your primary care doctor or another specialist only if you are referred by your own family doctor.

3. Worker's Compensation Insurance: If you are injuried in an automobile related accident while you are dicharging your duties as an employee, you may be entitled to coverage by worker's compensation insurance. A messenger side-swiped by a bus while delivering a package should be covered by worker's compensation insurance.

4. Medical Lien: When one is injured in an accident caused by another party who as at fault, he may be entitled to compensation by the other party under the law. However, if the injured does not have his own insurance or adequate coverage, he may have difficulty coming up with the finances to defray the medical costs for his treatments because it may take quite some time before he can obtain compensation for the responsible party under the law. Certain health professionals may be willing to accept an IOU from the patient providing the patient agrees to secure the IOU with future proceeds from the compensation he receives from the at fault party. This is known as a medical lien which is similar to a car loan using the car as a collateral or getting a loan for mortgaging one's house.

5. Medicaid (known in California as Medical): This is health insurance provided by the Federal or State government. It may cover some but not all of the treatment modalities.

_____________________________________________________________________

II. Injuries at the Workplace:

Thousands of people are injured daily while at work. There are generally two categories of work injuries, namely acute and chronic:

A. Acute injuries: Work injuries may be due to a myriad of causes including slipping and falling, lifting heavy loads, twisting arms and legs, chemical burns, falling objects, and flying projectiles. Generally, if acute injuries are properly treated, they may heal quickly; but frequently, a chronic component of disability may persist. For example, a dishwasher at a restaurant accidentally cut his finger with broken glass severing a nerve and a tendon. The nerve and the tendon were repaired surgically, the wound was sutured, and the finger healed quickly. In the ensuing months, however, severe pain developed and the pain gradually moved up from his finger to his hand and forearm and was accompanied with a marked difference in the skin's appearance. This patient suffers from what is known as reflex sympathetic dystrophy which is chronic and notoriously difficult to treat. Acute injuries as in injuries suffered in car accidents, if treated early and properly, can heal quickly and with a marked reduction of chronic problems. Unfortunately, most injuries, especially severe ones involving various kinds of muscular and tendon injuries as in back sprains, are not adequately treated. The patient is only given pain medication, muscle relaxant, and rest.

B. Chronic injuries: If one sustains repeated trauma, the cumulative injury may eventually reach a threshold where severe and disabling symptoms suddenly develop. A legal secretary who types several hours a day may have enough cumulative trauma to the finger joints to develop arthritis. A butcher using wrist motion a great deal for cutting can develop chronic pain at his wrist. A forklift operator that needs to use an arm to push a lever for several hours in a shift can experience chronic pain in his elbow. A trained engineer who needs to stick his head out of a window and look to one side to check for signals day after day may have chronic neck pain and headache. Repetitive trauma known as repetitive strain, does not even have to involve physical activities. In fact, physical inactivity may do just as much harm to the body. A computer operator who sits in a chair in the wrong position without taking frequent breaks may put enough strain on the back muscles to cause chronic back aches. A computer operator with his hand stretched forward without the proper elbow and arm supports can develop pain in both arms, often diagnosed as carpal tunnel syndrome. The reasoning is rather simple. Tense muscle causes pain and an immobile position actually requires the muscle to stay contracted to maintain that position. And after a long period, the muscle learns to stay tense all the time, and that makes it much more likely to hurt. If the process is repeated for months or years, problems will eventually develop.

C. Medical treatments commonly used to treat workplace injury:

1. Physical therapies, including hot and cold packs, electrical stimulation, massages, ultrasound treatments, infrared, and diathermy.

2. Trigger point injections.

3. Nerve blocks

4. Auriculoneural therapy

5. Acupuncture

6. Osteopathic or Chiropractic manipulation

7. Biofeedback

8. Hypnosis

9. Therapeutic Exercises

10. Traction

III. Sports Injuries:

A. Different parts of the body may be injured in different kinds of sports, and like injuries in the workplace, they may occur acutely or chronically. The incidence of specific types of injuries are commonly associated with a specific sport; for example, swimmers often get shoulder pain, tennis players tend to develop tennis elbow as well as knee and ankle pain, weightlifters often have back sprain, and athletes in contact sports often have severe sprains and contusions. Again, when injuries are treated mainly with pain medication, muscle relaxant, and rest, the internal pain mechanism set up by the injury may persist and become chronic if proper treatment is not given in the initial phase following the injury.

B. Special note: A situation unique to sports injuries is that the athlete who sustains the injury may try to ignore the warning signs of pain and continue with strenuous activities unabated. For instance, a basketball player who twists his ankle may continue to finish a game despite pain and swelling from a bad sprain. The continuous stress on an injured body part will lead to more severe injury and will likely lead to long-term adverse effects such as chronic pain.

C. Chronic Injuries from Sports: The situation is very similar to workplace injuries where repetitive strain or cumulative injury play an important role in the generation of pain. An avid tennis player or runner may continue to engage in strenuous sports despite development of what is initially felt as minor aches and pains. In the course of time, these minor aches and pains become incremental worse and with enough accumulation, a permanent pain circuit is set up which can perhaps lead to long-term impairment of physical functions. Since the injury is cumulative, the patient may not remember a specific episode which brought on the acute pain.

IV. Other injuries:

In addition to the above mentioned categories, physical injuries to the musculo-skeletal system can occur virtually at any place and many such incidents occur in none other than one's home. Consider the following cases:

1. A housewife developed chronic shoulder pain after doing a great deal of chopping in the kitchen in preparation for a large dinner party at home.

2. A veternarian developed pain in his right calf after a period of planting flowers in his hillside backyard at home after he spent many hours standing on the slope constantly putting his body weight on his right leg. His right leg was relatively uphill to the left leg. He was initially misdiagnosed as his family doctor as having a vascular problem.

3. A young professional remodeling his own home was hanging wallpaper for twelve hours a day for two consecutive days during a long weekend and consequently developed a strong shoulder and back ache. He was standing on the ladder for protracted periods of time putting an excessive amounts of strain on his back and shoulder on a flimsy old ladder.

4. A retired gentleman exerienced stiffness and pain in his neck for several weeks after he tried to fix the plumbing underneath his kitchen sink and kept his head and neck in an unnatural posture for hours.

Examples like the above simply cannot be ennumerated. Once again the ideal approach is to take care of the pain early by getting proper treatment as mentioned under treatment modalities to keep them from becoming chronic.

_________________________________________________________________

What health factors may contribute to the tenacity of chronic pain?:

Generally speaking, the healthier a person is, the less likely he is to develop chronic pain after a traumatic experience whether acutely or chronically.

Acute Pain & Chronic Pain Resulting From:

• Automobile Accident

• Car Accident

• Workplace Injuries

Pain as a Result of Diseased States

• Headaches

• T.M.J.

• Neck Pain

• Low Back Pain

• Sciatica

• Arthritis

• Causalgia

• Abdominal Pain

• Pain Following Operation

• Chest Pain

SOURCE: http://www.sfpain.com/

[Post-traumatic Stress Disorder And Fibromyalgia]

Post-Traumatic Stress Disorder and Fibromyalgia

In this study, researchers assessed the tenderness, sensitivity to pain, and distribution of fibromyalgia syndrome (FS)-related symptoms (such as pain sensitivity, sleep disturbances, headaches, etc.) in 29 post-traumatic stress disorder (PTSD) patients as compared to a control group of 37 healthy subjects. The goal was to determine the prevalence of FS in patients with PTSD, and to compare the differences between PTSD patients with and without FS.

Predictably, the PTSD patients reported higher levels of tenderness, a lower quality of life, and a higher rate of physical impairment. PTSD subjects also reported a significantly higher percentage of FS-related symptoms than their matched controls.

The researchers found that 20% of the PTSD subjects met the diagnostic criteria for FS. Patients with both conditions did not differ from those with only PTSD in terms of the core PTSD symptoms (i.e. intrusion and avoidance), but patients with both conditions had significantly higher scores on the SCL-90R. Those areas with particularly high scores were paranoia, phobia, anxiety, and depression.

The authors explore the relationship between the two conditions:

“The prevalence of 20% fibromyalgia syndrome found here is far greater than in the general population (2%)…The finding that there is a correlation between pain and PTSD is in accordance with earlier studies. Kuch et al. found that, among 60 patients treated for fibromyalgia syndrome in a pain clinic, the prevalence of phobias and PTSD were 3.2 times more common in victims of minor road vehicle accidents than in subjects with non-vehicular-related onset of pain…The present study indicates that fibromyalgia syndrome has a substantial overlap with PTSD, which supports the psychological background of the disorder.”

“The results of our study raise the question of whether fibromyalgia syndrome is, in fact, a stress-related disease. Goldenberg states that fibromyalgia syndrome is not a psychiatric disease, however, he emphasizes the relationship to psychological stress.”

Amir M, Kaplan Z, Neumann L, Sharabani R, Shani N, and Buskila D. Posttraumatic stress disorder, tenderness, and fibromyalgia. Journal of Psychosomatic Research 1997;42(6):607-613.

[What Is The Veterans Benefits Administration (vba) Appeals Management Center (amc)?]

AMC Information http://www.moaa.org/magazine/March2004/answer_digest.asp

What is the Veterans Benefits Administration (VBA) Appeals Management Center (AMC)?

The AMC was created [2003] to process appealed claims that have been remanded to the VBA by the Board of Veterans’ Appeals (BVA) or the Court of Appeals for Veterans Claims.

The AMC implements the BVA’s remand instructions involving evidence development and renders a decision on the claim.

The concentration of this appeals-processing expertise in one location is intended to improve the timeliness and accuracy of decisions. The AMC was established following a federal court decision that invalidated certain regulations of the BVA that permitted it to develop evidence on its own for claims it intended to remand to the VBA.

Why is the AMC in Washington, D.C.?

By law, the VA must process remands expeditiously, so VA officials decided to centralize this function. The Washington office is located blocks from the BVA, making the physical transfer of cases easier. The location also enables the AMC to take advantage of resources within the regional office and BVA and VBA headquarters.

What other changes are being made at the Washington office as a result of the establishment of the AMC?

In November 2003, the Pittsburgh office assumed responsibility for processing claims received from veterans and their dependents living abroad. These claims formerly were processed at the Washington office.

The Washington office also will devote resources to its Operation Early Intervention program, which provides assistance to severely disabled servicemembers hospitalized at Walter Reed Army Medical Center and Bethesda Naval Hospital.

APPEALS MANAGEMENT CENTER (AMC)

Department of Veterans Affairs

Appeals Management Center (AMC)

1722 Eye Street. NW

Washington, DC 20421

Toll Free Information line: 1-866-258-0341……….direct line(the one they will answer)- 1-202-565-5436

FAX- 1-202-530-9216

AMC fax line: 1-202-530-9383

Director: Keith Wilson

1-202-530-9400

Assistant Director: Keith McQuaid

1-202-530-9462

[Evidence Requirements]

Evidence Requirements

3.200 Testimony certified or under oath 3.200-1

3.201 Exchange of evidence; Social Security and Department of

Veterans Affairs 3.201-1

3.202 Evidence from foreign countries 3.202-1

3.203 Service records as evidence of service and character of discharge 3.203-1

3.204 Evidence of dependents and age 3.204-1

3.205 Marriage 3.205-1

3.206 Divorce 3.206-1

3.207 Void or annulled marriage 3.207-1

3.208 Claims based on attained age 3.208-1

3.209 Birth 3.209-1

3.210 Child’s relationship 3.210-1

3.211 Death 3.211-1

3.212 Unexplained absence for 7 years 3.212-1

3.213 Change of status affecting entitlement 3.213-1

3.214 Court decisions; unremarried widows 3.214-1

3.215 Termination of marital relationship or conduct 3.215-1

3.216 Mandatory disclosure of social security numbers 3.216-1

§3.200 Testimony certified or under oath.

(a) All oral testimony presented by claimants and witnesses on their behalf before any rating or authorization body will be under oath or affirmation. (See §3.103©.)

(b) All written testimony submitted by the claimant or in his or her behalf for the purpose of establishing a claim for service connection will be certified or under oath or affirmation. This includes records, examination reports, and transcripts material to the issue received by the Department of Veterans Affairs at the instance of the claimant or in his or her behalf or requested by the Department of Veterans Affairs from State, county, municipal, recognized private institutions, and contract hospitals.

[40 FR 36329, Aug. 20, 1975]

[Us Admits Germ Warfare Tests During Cold War]

09 Oct 2002 21:37

US admits germ warfare tests during Cold War

By Charles Aldinger

WASHINGTON, Oct 9 (Reuters) - The United States acknowledged

on Wednesday it carried out a sweeping Cold War-era test program

of chemical and germ warfare agents on American soil and in Britain

and Canada.

An unknown number of civilians were exposed at the time to "simulants,"

or what were then thought to be harmless agents meant to stand in for

deadlier ones, the Defense Department said. Some of those were later

discovered to be dangerous.

"We do know that some civilians were exposed in tests that occurred in

Hawaii, possibly in Alaska and possibly in Florida," said William

Winkenwerder, assistant secretary of defense for health affairs.

Also exposed or possibly exposed were civilians in or around Vieques,

Puerto Rico, and an unknown number of U.S. service personnel, said

Michael Kilpatrick of the Pentagon's Deployment Health Support

Directorate.

As many as 5,500 members of the U.S. armed forces were involved,

including 5,000 who took part in previously disclosed ship-board

experiments in the Pacific in the 1960s, the Pentagon said.

So far, more than 50 veterans have filed claims related to symptoms

they associate with exposure to the tests, the Department of Veterans

Affairs said.

The tests of such nerve agents as Sarin, Soman, Tabun and VX were

carried out from 1962 to 1973 both on land and at sea "out of concern

for our ability to protect and defend against these potential threats," a

Pentagon statement said. The tests were coordinated by an outfit called

the Deseret Test Center at Fort Douglas, Utah.

The reports amounted to an acknowledgment of much wider Cold War

testing of toxic arms involving U.S. forces than earlier admitted by the

Pentagon.

"During this period there were serious and legitimate concerns about

the Soviet Union's chemical and biological warfare program,"

Winkenwerder added at a Pentagon news briefing.

But the tests also had applications to the offensive chemical and

biological weapons stocks then maintained by the United States,

he said. President Richard Nixon ordered an end to U.S. offensive

chemical and biological weapons programs in 1970.

Britain and Canada joined the United States in a series of tests on

their military proving grounds from July 1967 to September 1968, a

document released by the Pentagon said.

These joint exercises, known as Rapid Tan 1, 2 and 3, were designed

to investigate "the extent and duration of hazard" following a Tabun,

Soman or other nerve agent attack, a fact sheet said. These agents,

along with VX, were sprayed in both open grassland and wooded

terrain at Britain's Chemical Defence Establishment in Porton Down,

England, the document said.

Similar tests took place at the Suffield Defence Research Establishment

in Ralston, Canada, the Pentagon said.

"The weapons systems germane to this test were explosive munitions

(Soman-filled), aircraft spray, rain-type munitions (using both Tabun

and Soman), and massive bombs (Tabun- and Soman-filled), the fact

sheet said.

CANADA, BRITAIN

Both Canada and Britain made public information about these tests

years ago, Kilpatrick said, citing word received from their governments

as part of the process of coordinating the U.S. release of information.

But in Ottawa, Canadian Defense Minister John McCallum told reporters

he had just learned of the experiments.

"My understanding is that this was ... for the purposes of defense

against biological or chemical weapons ... My understanding also is

that no human beings were deliberately exposed to any of these

agents." he said.

The department said it had contracted with the Institute of Medicine,

a private group with ties to the National Academy of Sciences, to

carry out a three-year, $3 million study of potential long-term health

effects of the tests conducted aboard U.S. Navy ships.

The reports on the U.S. land tests in Alaska, Hawaii, Maryland and

Florida did not all involve deadly agents and were used to learn how

climate and a battle environment would affect the use of such arms,

the Pentagon said.

The information was released amid U.S. charges that Iraq has

continued building weapons of mass destruction despite disarmament

requirements at the end of the 1991 Gulf War.

Iraq flatly denies having such weapons programs.

Within minutes, Sarin can trigger symptoms including difficult

breathing, nausea, jerking, staggering, loss of bladder-bowel control

and death.

Extremely lethal VX is an oily liquid that is tasteless and odorless and

considered one of the most deadly agents ever made by man. With

severe exposure to the skin or lungs, death usually occurs within 10

to 15 minutes.

IMMEDIATE RELEASE

October 9, 2002

(703)697-5737(public/industry)

DOD RELEASES DESERET TEST CENTER/

PROJECT 112/PROJECT SHAD FACT SHEETS

The Department of Defense today released another 28 detailed

fact sheets on 27 Cold War-era chemical and biological warfare

tests identified as Project 112. Project 112 was a

comprehensive program initiated in 1962 out of concern for our

ability to protect and defend against these potential threats.

This is in addition to the 12 fact sheets for 10 tests released

in September 2001 and January and May this year. Release of the

information is part of an on-going effort to provide information

needed by the Department of Veterans Affairs to respond to some

veterans' claims that tests conducted in the 1960s and early

1970s may have affected their health. The new fact sheets cover

tests performed both at sea and on land. A DoD investigative

team found that actual chemical and biological warfare agents

and simulants for these agents were used in some of these tests.

Equipment and Terrain Testing

From 1962 to 1973, the Deseret Test Center, headquartered at

Fort Douglas, Utah, conducted a series of chemical and

biological warfare vulnerability tests in support of Project

112. The Deseret Test Center planned 134 tests with 46

confirmed to be conducted and 62 canceled. Currently, DoD

investigators are searching for final reports on five tests, an

additional four tests are pending review, and the status of 26

other planned tests is still under investigation.

The purpose of the tests done under Project Shipboard Hazard and

Defense was to identify U.S. warships' vulnerabilities to

attacks with chemical or biological warfare agents and to

develop procedures to respond to such attacks while maintaining

a war-fighting capability. The purpose of the land-based tests

was to learn more about how chemical or biological agents behave

under a variety of climatic, environmental and use conditions.

Today's release:

<http://www.defenselink.mil/news/Oct2002/d20021009112.pdf>

includes fact sheets about two tests conducted off the coast of

California, two tests conducted in the coastal waters of Hawaii,

one test conducted in Puerto Rico, and one test conducted on

Baker Island as part of Project SHAD. The remainders are

land-based tests conducted in Alaska (11), Florida (one), Hawaii

(three), Maryland (one), Utah (three), Canada (one), and one

test done jointly in the U.K. and Canada. Of the 28 fact sheets

released today, 12 detail the use of simulants and 16 detail the

use of live chemical or biological agents in the tests.

Veterans' Concerns

The Department of Defense began investigating the shipboard

hazard and defense tests in September 2000, after the Department

of Veterans Affairs asked the DoD for information needed to

clarify claims information from servicemembers who believed they

might have been exposed to harmful substances during their

participation in tests. The VA claims experts needed to know

what substances veterans may have been exposed to and who might

have been exposed. DoD agreed to deliver that information when

it could be found.

An investigative team located and searched classified records to

identify which ships and units were involved in the tests, when

the tests took place, and to what substances their crews and

other personnel may have been exposed. This required

declassification of test-related ship and location information,

without release of information that remains classified for valid

operational security reasons.

As DoD's investigators continued their examination of the facts

associated with these tests, it became clear that an

investigation of all the tests conducted by the Deseret Test

Center was necessary. Consequently, early this year the

investigation of shipboard hazard and defense tests was expanded

to include all tests conducted by the Deseret Test Center.

Health and Safety

While some may be concerned about a possible connection between

an exposure in the 1960s or 1970s and a later illness, DoD

investigators have not identified a link to these tests and

adverse health consequences. Documents show that these were

comprehensive tests that carefully considered the health and

safety of the personnel involved in conducting the tests and

protecting the environment. The DoD investigation into Deseret

Test Center tests continues, and DoD is committed to releasing

as much information as possible on all tests conducted.

Veterans who believe they were involved in Deseret Test Center

tests and desire medical evaluations should call the VA's

Helpline at (800) 749-8387. Veterans who have DoD related

questions, who have information to contribute, or who are DoD

beneficiaries and have medical concerns or questions, should

call DoD's Deployment Health Support Directorate's contact

center at (800) 497-6261. All Deseret Test Center fact sheets

are available on the DeploymentLINK Web site at

<http://deploymentlink.osd.mil/current_issues/shad/shad_intro.shtml>.

gulflink@yahoogroups.com is a service

of <http://www.gulflink.org.>

[Deluca Vs Brown]

UNITED STATES COURT OF VETERANS APPEALS

No. 94-242

Guido DeLuca, Appellant,

v.

Jesse Brown,

Secretary of Veterans Affairs, Appellee.

On Appeal from the Board of Veterans' Appeals

(Argued July 31, 1995 Decided September 22, 1995 )

Susan Paczak for the appellant.

Amy S. Gordon, with whom Mary Lou Keener, General Counsel; Norman G. Cooper, Assistant General Counsel; and Adrienne Koerber, Deputy Assistant General Counsel, were on the brief, for the appellee.

Before NEBEKER, Chief Judge, and KRAMER and STEINBERG, Judges.

STEINBERG, Judge: The appellant, Korean conflict veteran Guido DeLuca, appeals an October 28, 1993, Board of Veterans' Appeals (BVA or Board) decision denying entitlement to an increased disability rating for a left-shoulder disorder, currently evaluated as 20% disabling. Record (R.) at 9. Both parties filed briefs. This is the second time this case has been before the Court. The BVA decision currently here on appeal was issued pursuant to a May 1993 Court decision vacating a June 1991 Board decision and remanding the matter. For the reasons that follow, the Court will vacate the October 1993 Board decision and remand the matter again.

I. Background

The veteran served on active duty in the U.S. Army from October 1952 to October 1954. R. at 51. He asserts that his entire left side, including his shoulder, was injured "when a shell exploded near him" during service. Brief (Br.) at 7; see also R. at 100-01. A service medical record (SMR) dated July 1954 records the veteran's complaint of "shrapnel" in his foot (R. at 38), but there is no diagnosis of or treatment for a shrapnel injury noted in his SMRs (see R. at 23-51, 100, 107, 144). In March 1984, the BVA recommended that service connection be awarded administratively by the Veterans' Administration (now Department of Veterans Affairs) (VA) for "arthralgia of the left shoulder". R. at 145. ("Arthralgia" is "pain in a joint", Dorland's Illustrated Medical Dictionary 147 (27th ed. 1988).) A February 1985 VA regional office (RO) decision granted service connection for left-shoulder arthralgia, effective from February 1982, rated 0% disabling. In an April 1987 decision, the Board granted entitlement to a 10% disability rating for left-shoulder arthralgia, effective from February 1982. R. at 206, 208.

A private orthopedist, Dr. Levine, in a March 1989 medical report, noted an impression of "scapulothoracic bursitis, left arm", and found the patient to be "totally asymptomatic" at that time. R. at 255. The veteran also submitted an April 1989 statement from a private physician, Dr. Scherer, who stated that when he had evaluated the veteran in September 1988 "he was having constant throbbing pain [and] was unable to raise his left arm above his head and in fact he could only abduct his arm at 45ø from the body"; the physician further noted that "it is going to be a chronic problem and it does tend to flare [up] at times although he will have some good days." R. at 212.

A June 1989 VA medical examination report diagnosed a "[f]rozen [l]eft shoulder" and "arthritis [of the] cervical spine (C 5-7)". R. at 218. An April 1990 VA medical examination report noted that left-shoulder abduction was 50ø, anterior extension was 40ø, posterior extension was 35ø, and internal rotation was "only slightly limited". R. at 246. The "impression" was "frozen shoulder syndrome on the non-dominant side with some degree of psychogenic overlay" and that "restricted mobility . . . was in part due to voluntary guarding." R. at 247. A June 1990 VARO decision increased the left-shoulder rating to 20% disabling, effective May 1989. The BVA denied a further increase in the rating in a June 6, 1991, decision (R. at 312), and the veteran appealed to this Court.

In May 1993, the Court issued a memorandum decision vacating the June 1991 BVA decision and remanding the matter for "prompt further readjudication, consistent with this decision, on the basis of all evidence and material of record and all applicable law and regulation". DeLuca v. Brown, 6 Vet.App. 321 (1993) (mem. dec.). The Court ordered the Board to consider the application of 38 C.F.R. § 4.40 regarding functional loss due to pain; 38 C.F.R. § 4.45 regarding weakness, fatigability, incoordination, or pain on movement of a joint; and the Court's decisions in Schafrath v. Derwinski, 1 Vet.App. 589 (1991), and Ferraro v. Derwinski, 1 Vet.App. 326 (1991).

The October 1993 BVA decision currently here on appeal was issued pursuant to the Court's May 1993 memorandum decision. The record does not indicate that the BVA undertook any further factual development on remand, or that the veteran submitted additional evidence or comment. The BVA determined that §§ 4.40 and 4.45 did not provide for an increased rating for the veteran's left-shoulder disability because that disability had been rated under 38 C.F.R. § 4.71, Diagnostic Code (DC) 5201, which "contemplates the functional loss resulting from pain on undertaking motion." R. at 12. The BVA further determined that § 4.45 did not provide for an increased rating in the instant case because "[w]eakened movement and excess fatigability usually are associated with muscle injury"; because "ncoordination is usually associated with disease or injury affecting the peripheral nerves"; and because this veteran's disability was not associated with "nerve injury" or "muscle injury, as such, to the left shoulder girdle". R. at 12-13.

II. Analysis

A. 38 C.F.R. § 4.40

In its October 1993 decision, the BVA cited DC 5201, which provides the following disability ratings for limitation of motion of the minor arm:

To 25ø from side . . . . . . . . . . . . . . . . . . . . . . 30%

Midway between side and shoulder level . . . . 20%

At shoulder level . . . . . . . . . . . . . . . . . . . . . . 20%

38 C.F.R. § 4.71, DC 5201 (1994). The Board found that no increase was warranted in the veteran's 20% disability rating because the April 1990 VA examination report had indicated that his left-shoulder anterior extension was 40ø and abduction was 50ø and these motion ranges more closely approximated the 45ø which constitutes motion to "[m]idway between side and shoulder level" than they did the motion range to 25ø required for a 30% rating. R. at 10-11; see 38 C.F.R. § 4.7 (1994) ("Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.").

The regulation for musculoskeletal-system functional loss in § 4.40 provides:

Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity[,] or the like.

38 C.F.R. § 4.40 (1994) (emphasis added). The BVA stated that it was not necessary to rate the veteran's pain separately under § 4.40 in the instant case because "where a diagnostic code, such as 5201, provides a compensable rating for limitation of motion of a major joint, that compensable rating contemplates the functional loss resulting from pain on undertaking motion" (R at 11-12), and thus, the Secretary concludes, the Board did apply § 4.40 sufficiently (Br. at 10). In support of its conclusion, the Board cited 38 C.F.R. § 4.14, "Avoidance of pyramiding", which provides:

The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Dyspnea, tachycardia, nervousness, fatigability, etc., may result from many causes; some may be service connected, others, not. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided.

38 C.F.R. § 4.14 (1994).

The Board's and the Secretary's interpretation is that, because pain can cause limitation of motion, any regulation that specifies a rating for limitation of motion ipso facto includes a rating for pain, and thus the application of _ 4.40 in the instant case would constitute pyramiding of ratings. The Secretary asserts that, although "the BVA may have been overbroad in its discussion regarding [DCs] involving limitation of motion", the Board was nevertheless correct in its assertion that pain was considered in rating the veteran in this particular case. Br. at 10. The Secretary cites the April 1990 VA medical examination report which noted that the veteran's range of motion was affected by "voluntary guarding" (R. at 247), and argues that, "[c]onsequently", the veteran's "pain was considered in determining the appropriate evaluation for his disability". Br. at 10. In fact, the Board stated specifically:

In the present case, the veteran's complaints of pain have been considered . . . . We note that the examiner indicated that the veteran's range of motion was limited by guarding. Thus, the presence of or anticipation of pain in the left shoulder prevented the veteran from attaining fuller range of motion than demonstrated on examination. The veteran's current award is based, in part, on his left shoulder pain which inhibits left shoulder motion.

R. at 12.

Range of motion undoubtedly can be affected by pain in certain situations, and a limitation of motion due to pain might indeed be reflected in a rating under DC 5201. However, _ 4.40 specifically refers to disability due to lack of normal "endurance", provides for a rating to be based on "functional loss . . . due to . . . pain", and states that "a part which becomes painful on use must be regarded as seriously disabled" (emphasis added). Furthermore, _ 4.40 provides that "t is essential that the [rating] examination . . . adequately portray the . . . functional loss" (emphasis added). The veteran has testified under oath that his arm becomes painful on use during the winter months and causes him to miss work (R. at 14, 235-36), and there is medical evidence that his shoulder condition will flare up at times (R. at 212).

The April 1990 VA examination relied upon by the BVA merely recorded the veteran's range of motion at that time, and did not indicate consideration of the factors cited in _ 4.40, and required by _ 4.40 to be considered and portrayed in the rating examination, as to functional loss on use or due to flare-ups. See Voyles v. Brown, 5 Vet.App. 451, 453 (1993) (Board decision "specifically noted the limitation of motion" but "failed to make any findings as to the extent of the appellant's pain on motion" pursuant to __ 4.40 and 4.45 (emphasis added)); see also Ferraro, 1 Vet.App. at 330. When a medical examination report "does not contain sufficient detail", the adjudicator is required to "return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2 (1994); see also Bierman v. Brown, 6 Vet.App. 125, 129 (1994) (medical examiner must "furnish[], in addition to the etiological, anatomical, pathological, laboratory[,] and prognostic data required for ordinary medical classification, full description of the effects of disability upon the person's ordinary activity") (quoting 38 C.F.R. § .10 (1994)); Schafrath, 1 Vet.App. at 595. Accordingly, the case must be remanded for the Board to obtain a new medical examination which complies with the requirements of §4.40, and the medical examiner must be asked to express an opinion on whether pain could significantly limit functional ability during flare-ups or when the arm is used repeatedly over a period of time. See Voyles, 5 Vet.App. at 454. Because DC 5201 provides for a rating solely on the basis of loss of range of motion, these determinations should, if feasible, be "portray[ed]" (§4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. Cf. Lathan v. Brown, 7 Vet.App. 359, 367 (1995) (in ordering medical opinion on remand in dependency and indemnity compensation case, VA should "consider the feasibility of requesting that the physician express in percentage terms the probability that the veteran's service-connected disability caused or contributed to death").

The Court holds that DC 5201 does not subsume 38 C.F.R. §4.40, and that 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use including during flare-ups. See Schafrath, 1 Vet.App. at 592-93 (holding that BVA's failure to consider § 4.40 was improper when that regulation had been made potentially applicable through assertions and issues raised in record); see also Quarles v. Derwinski, 3 Vet.App. 129, 139-40 (1992).

B. 38 C.F.R. § 4.45

The Court's May 1993 memorandum decision noted that 38 C.F.R. § 4.45 "provides that in rating disabilities of joints, `inquiry will be directed to' `[w]eakened movement', `[e]xcess fatigability', `ncoordination', and `[p]ain on movement', in addition to limitation of motion." DeLuca, 6 Vet.App. at 324. The October 1993 BVA decision declined to apply _ 4.45 in the instant case on the grounds that "[w]eakened movement and excess fatigability usually are associated with muscle injury" and "ncoordination . . . is usually associated with disease or injury affecting the peripheral nerves of the upper extremity", whereas the veteran's left-shoulder condition "has never been associated with muscle injury as such" and there was no "nerve injury". R. at 12-13. The Secretary adopted this argument. See Br. at 11. The Board cited the report from Dr. Levine, which stated that no significant atrophy of the left-shoulder girdle was found, and the 1990 VA medical report, which "described no weakness of movement or excess fatigability of the left shoulder girdle musculature." R. at 13. However, the 1990 VA medical report did not specify that there was no weakness of movement or excess fatigability of the left shoulder girdle musculature; it did not address these issues. R. at 245-47.

The Board's reading of _ 4.45 cannot be sustained. The plain language of _ 4.45 indicates that "[w]eakened movement", "[e]xcess fatigability", and "ncoordination" do not refer solely to muscle and nerve conditions. First, the title of the regulation is "The joints", not "The muscles" or "The nerves". Cf. 38 C.F.R. § 4.50 ("Muscle injuries"); 38 C.F.R. § 4.51 ("Muscle weakness"); 38 C.F.R. § 4.52 ("Muscle damage"); 38 C.F.R. § 4.53 ("Muscle patterns"); and 38 C.F.R. § 4.54 ("Muscle groups"). Second, the first sentence of the regulation refers to the "factors of disability" of "the joints", and does not refer to muscles or nerves. Third, the parenthetical in paragraph © following "[w]eakened movement" refers to "muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.". If "weakened movement" were intended to refer exclusively to muscle or nerve disability, the regulation would not mention "tendons" and would not say "etc.". The purpose of the list is to indicate that muscle and nerve disabilities are merely two of the factors that should be considered. Fourth, paragraphs (d) and (e), while referring to "[e]xcess fatigability" and "ncoordination", do not limit their application to muscles or nerves. Accordingly, VA's interpretation of its regulation, even if that interpretation predated this litigation, see Tallman v. Brown, 7 Vet.App. 453, 463-65 (1995), is in conflict with the plain meaning of the regulation and therefore entitled to no deference. See Combee v. Principi, 4 Vet.App. 78, 91 (1993) (administrative agency's interpretation of regulation may be entitled to deference where meaning is unclear and interpretation "sensibly conforms to the purpose and wording of the regulations") (quoting Martin v. Occupational Health and Safety Review Comm'n, 499 U.S. 144, 151 (1991)), rev'd on other grounds sub nom. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Combee v. Brown, 5 Vet.App. 248, 257 (1993) (Steinberg, J., dissenting) (agency interpretation of regulation is not entitled to deference if inherently unreasonable).

Additionally, the medical records in this case do not expressly establish that there is no involvement of muscles or nerves in the veteran's disability. Therefore, it was error for the Board to so conclude based on its own medical judgment. See Colvin v. Derwinski, 1 Vet.App. 171, 175 (1991) ("BVA panels may consider only independent medical evidence to support their findings" and may not "refut[e] the expert medical conclusions in the record with [their] own unsubstantiated medical conclusions").

Consequently, in the examination ordered on remand, the medical examiner should be asked to determine whether the left-shoulder joint exhibits weakened movement, excess fatigability, or incoordination, and such inquiry should not be limited to muscles or nerves. See Bierman, supra. As noted above, these determinations should, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. Cf. Lathan, supra. (The Court notes that an evaluation of "pain on movement" pursuant to _ 4.45 would seem in this case to be duplicative of the _ 4.40 requirement that pain on use must be evaluated.)

C. Applicability of Schafrath v. Derwinski

The Court's May 1993 decision directed the BVA to consider Schafrath, supra. The Board decision attempted to distinguish Schafrath by stating that in that case the veteran had complaints of pain for which he was not being compensated because he had a noncompensable rating, whereas in the instant case the veteran is being compensated by his current 20% rating for his disability due to pain. The Secretary adopted this argument. See Br. at 13. In light of the Court's holding that DC 5201 does not subsume 38 C.F.R. §§ 4.40 and 4.45, the Board's conclusion is flawed. See Quarles, supra. On remand, the Board must consider the application of Schafrath, Quarles, and Ferraro, all supra, to the veteran's claim.

D. Reasons or Bases

The Court stated in its May 1993 decision that "[d]etermination of whether the application of sections 4.40 and 4.45 entitles the veteran to an increased rating requires factual findings as to the extent to which the veteran's left-shoulder pain and weakness cause additional disability beyond that reflected in the measured limitation of his left-shoulder motion." DeLuca, supra. The Board's statement of the reasons or bases for its October 1993 decision was not adequate under 38 U.S.C. § 7104(d)(1). The Board did not explain how pain on use was factored into its evaluation of the veteran's disability in terms of limitation-of-motion equivalency under DC 5201. For example, the Board found that the veteran's testimony was credible that in the winter months his shoulder condition caused him to miss "2 or 3 days of work a week". R. at 14. Yet, the Board did not explain how this impairment of the veteran's employment was evaluated under DC 5201 and § 4.40. Cf. 38 C.F.R. § 4.10 ("basis of disability evaluations is the ability . . . to function under the ordinary conditions of daily life including employment"; medical examination must furnish "full description of the effects of disability upon the person's ordinary activity. . . ; person may be too disabled to engage in employment although he or she is up and about and fairly comfortable at home or upon limited activity") (emphasis added).

III. Conclusion

Upon consideration of the record and the submissions and arguments of the parties, the Court vacates the October 28, 1993, BVA decision and remands the matter for expeditious further proceedings, on the basis of all applicable law and regulation, and issuance of a readjudicated decision supported by an adequate statement of reasons or bases, see 38 U.S.C. §§ 1310, 5107(a), 7104(d)(1), 7261; 38 C.F.R. § 4.71a; Fletcher v. Derwinski, 1 Vet.App. 394, 397 (1991) -- all consistent with this opinion and in accordance with section 302 of the Veterans' Benefits Improvements Act, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994) (found at 38 U.S.C. § 5101 note) (requiring Secretary to provide for "expeditious treatment" for claims "remanded" by BVA or the Court). See Mason v. Brown, __ Vet.App. __, __, No. 93-1111, slip op. at 25-26 (June 26, 1995). On remand, the appellant will be free to submit additional evidence and argument on the remanded claim, and the Secretary will be free to seek further development. See Quarles, 3 Vet.App. at 141. A final decision by the Board following the remand herein ordered will constitute a new decision which, if adverse, may be appealed to this Court only upon the filing of a new Notice of Appeal with the Court not later than 120 days after the date on which notice of the new Board final decision is mailed to the appellant.

VACATED AND REMANDED.

[Sec. 3.310 Proximate Results, Secondary Conditions.]

[Code of Federal Regulations]

[Title 38, Volume 1, Parts 0 to 17]

[Revised as of July 1, 1998]

From the U.S. Government Printing Office via GPO Access

[CITE: 38CFR3.310]

[Page 224]

TITLE 38--PENSIONS, BONUSES, AND VETERANS' RELIEF

CHAPTER I--DEPARTMENT OF VETERANS AFFAIRS

PART 3--ADJUDICATION--Table of Contents

Subpart A--Pension, Compensation, and Dependency and Indemnity

Compensation

Sec. 3.310 Proximate results, secondary conditions.

(a) General. Disability which is proximately due to or the result of

a service-connected disease or injury shall be service connected. When

service connection is thus established for a secondary condition, the

secondary condition shall be considered a part of the original

condition.

(b) Cardiovascular disease. Ischemic heart disease or other

cardiovascular disease developing in a veteran who has a service-

connected amputation of one lower extremity at or above the knee or

service-connected amputations of both lower extremities at or above the

ankles, shall be held to be the proximate result of the service-

connected amputation or amputations.

(Authority: 38 U.S.C. 501, 1110-1131)

[44 FR 50340, Aug. 28, 1979]

[Samuels V. West]

DOCKET NO.: 96-402 ACTIVITY: RATING

NAME: Samuels v. West

ISSUE(S): Well-grounded claim

ACTION BY COURT: Affirmance DECISION DATE: 9/23/98

FACTS:

The veteran entered service in October 1970. The entrance physical examination report recorded a normal psychiatric condition. Seventeen days after the veteran entered service, a medical report noted he complained of being scared around weapons because he had accidentally shot a girlfriend prior to service. An Army medical board restricted the veteran from the use of weapons. He was subsequently discharged after serving three months and twenty-three days for failing to meet medical fitness standards at the time of his induction.

More than four years after his discharge, the veteran filed a claim for service connection of a nervous disorder. The Board denied this claim in October 1977, finding that there was no confirmed psychiatric disorder until 1976, more than four years after the veteran’s separation from service. Over the years, the veteran received many various diagnoses of psychiatric disorders, not including PTSD. In March 1991, he filed a claim for PTSD and submitted a December 1989 psychological report which showed a diagnosis of PTSD and included a history supplied by him of his having PTSD from Vietnam. In a December 1991 VA psychiatric examination, the veteran “remembered” more combat experiences, alleging that he had seen many people killed. Atypical psychosis was diagnosed and the “stress of military service” was listed as an environmental factor.

A July 1994 BVA decision remanded the veteran’s PTSD claim and ordered the RO to determine the exact nature of the veteran’s mental condition and alleged PTSD stressor. After the BVA remand, the RO obtained multiple medical reports showing that the veteran had PTSD as a result of his alleged Vietnam experiences. During a February 1995 VA examination, the veteran admitted that he had not been in combat, but asserted that he had been in Vietnam. The diagnoses provided were paranoid schizophrenia and dependent personality traits. The “stress of [m]ilitary experience” was listed as an environmental factor. PTSD was not diagnosed, but the examiner commented that “there is much evidence to diagnosis PTSD in my opinion.”

The BVA, in a March 1996 decision, determined that the preponderance of the evidence was against the veteran’s PTSD claim. The BVA found that, based on the Diagnostic and Statistical Manual of Mental Disorders, third edition, (DSM-III), there was no evidence of a stressor that would support a diagnosis of PTSD.

ANALYSIS:

The Court noted that a well-grounded PTSD claim is one where the claimant has “submitted medical evidence of a current disability; lay evidence …of an in-service stressor, which in a PTSD case is the equivalent of in-service incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD disability.” Cohen v. Brown, 10 Vet.App. 128, 137 (1997). The appellant’s evidentiary assertions must be accepted as true for the purpose of determining whether the claim is well grounded. The exceptions to this rule occur when the evidentiary assertion is inherently incredible, or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet.App. 19, 21 (1993).

The veteran’s PTSD diagnoses were based upon his fictitious recitation of combat experience in Vietnam. None of the PTSD diagnoses referred to any non-fictional in-service incident, such as fear of weapons, as a potential in-service stressor. For the purpose of determining whether the veteran has submitted a well-grounded PTSD claim, the alleged stressor is his combat experience in Vietnam. However, the record is clear that the veteran had no service in Vietnam. Although lay evidence of a PTSD stressor is generally presumed to be truthful, in this case the veteran’s testimony as to his Vietnam combat experience is inherently incredible, and neither the Board nor the Court is required to accept his assertions as true. Cf. King, 5 Vet.App. at 21. Because the veteran did not submit credible evidence of an in-service stressor, and thus no evidence of service incurrence, his PTSD claim is not well grounded.

IMPACT ON DECISIONMAKERS: The decision in this case is consistent with Court caselaw on well-grounded claims. This decision does not warrant a change in current regulations, policies, or procedures.

RECOMMENDED VBA ACTION(S): None

Approved?

X ___ /s/ 11/23/98

Yes No Robert J. Epley Date