Entitlement to secondary service connection for obstructive sleep apnea (OSA) is granted.

Citation Nr: 26001386 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 13-29 842 DATE: January 30, 2026 ORDER Entitlement to secondary service connection for obstructive sleep apnea (OSA) is granted. FINDING OF FACT The Veteran's OSA is proximately due to her service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to secondary service connection for OSA are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from January 2000 to April 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In September 2017, the Board remanded this matter to afford the Veteran a hearing. In June 2021, the Veteran testified at a virtual hearing before the undersigned. In January 2024, the Board remanded this matter for additional development. Substantial Compliance The Board directed the AOJ to obtain complete VA treatment records and any outstanding relevant non-VA treatment records. The AOJ achieved substantial compliance with these directives. The Board also directed the AOJ to obtain several medical opinions addressing the nature and etiology of the Veteran's OSA, and the AOJ complied. Although the AOJ did not obtain an opinion addressing the combined impact of the Veteran's service-connected disabilities, the Board did not require such an opinion. Rather, the Board's directives stated that it would be "preferable" if such an opinion could be obtained. As explained below, adjudication of this matter on the present record is appropriate, notwithstanding that not all of the opinions obtained by the AOJ are supported by adequate rationales. Service Connection for OSA The Veteran asserts that her OSA is related to her service, as she has had difficulty sleeping since an in-service neck injury. See, e.g., November 2016 Correspondence. She also asserts that her OSA may be related to her service-connected disabilities, as well as medication that she takes to treat these disabilities. See, e.g., December 2016 VA Form 9. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection generally requires evidence showing (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Secondary service connection may be granted for a disability that is due to or that has been aggravated (made worse) by a service-connected disability. 38 U.S.C. § 1110; 38 C.F.R. § 3.310. The Veteran has a current diagnosis of OSA. See, e.g., December 2016 Sleep Apnea Disability Benefits Questionnaire (DBQ). Moreover, during service she was in a car accident and sustained injuries, including a neck injury, and she was prescribed medications to treat these injuries. See, e.g., Adult Preventative and Chronic Care Flowsheet. Additionally, the Veteran is service connected for numerous disabilities, including posttraumatic stress disorder (PTSD), gastritis, hyperthyroidism, and musculoskeletal disabilities of the left shoulder, lumbosacral spine, and cervical spine. Thus, the first and second elements of direct and secondary service connection are met, and this appeal turns on whether there is a nexus linking the Veteran's current OSA and her service, her service-connected disabilities, or medication she takes to treat her service-connected disabilities. OSA is defined as "sleep apnea resulting from collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep. In adults it is seen primarily in middle-aged individuals, with a male predominance." See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 118 (31st ed. 2007). Apnea is defined as "cessation of breathing." Id. The Veteran's service treatment records (STRs) document that she was prescribed Flexeril and other medications after sustaining injuries in an in-service car accident. See, e.g., Adult Preventative and Chronic Care Flowsheet; October 24, 2000 Treatment Note. Her STRs also confirm sleep problems, including waking up in the middle of the night short of breath, as well as drowsiness. See, e.g., June 22, 2000 STR; July 13, 2000 STR. Flexeril is the brand name of cyclobenzaprine hydrochloride. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 725 (31st ed. 2007). Cyclobenzaprine hydrochloride is used as a muscle relaxant for relief of painful muscle spasms. Id. at 463. Additionally, the Veteran has been prescribed methocarbamol for treatment of muscle spasms. See, e.g., December 10, 2015 VA Medication Note. Methocarbamol is also a muscle relaxant. See DORLAND'S, at 1165. A medical dictionary defines a muscle relaxant as "an agent that specifically aids in reducing muscle tension." Id. at 1646. The August 2024 examiner's opinions explain that OSA is an anatomical problem with soft tissue in the upper airway at the posterior pharynx, which occludes the airway and prevents breathing for a brief period. See, e.g., August 2024 Medical Opinion (TMJ). Another opinion is more specific, explaining that OSA occurs when the muscles in the back of the throat relax too much to allow for proper breathing, as when these muscles relax the airway narrows or closes. See, e.g., August 2024 Medical Opinion (Direct Service Connection). The opinions also explain that the most common cause for OSA in adults is excess weight and obesity, which is associated with the soft tissue of the mouth and throat. See id. The examiner correctly observed that the Veteran "is obviously not obese." Id. The August 2024 examiner provided several opinions as to why specific service-connected disabilities did not cause or worsen the Veteran's OSA. As discussed below, several of these opinions have contradictory rationales. With respect to PTSD, the examiner noted that research showed that PTSD and OSA were often co-morbid, "with a likely bidirectional effect of the two illnesses. There is substantial evidence to support the role that disturbed sleep may play in the pathophysiology of OSA." The examiner went on to explain that "[i]n simpler terms, it is more likely that the obstructive sleep apnea impacts PTSD than the other way around." See August 2024 PTSD Opinion. The August 2024 examiner did not accurately characterize the cited study. While the quoted part of the study did not include any comment regarding the quantity of evidence showing how PTSD affected OSA, the study also did not include any statement that OSA more likely caused PTSD than PTSD caused OSA. Rather, the study said that PTSD likely causes OSA and that OSA likely causes PTSD, and moreover there was substantial evidence that disturbed sleep causes OSA. As the examiner's rationale mischaracterized this study, the opinion against the claim is not probative. See McCray v. Wilkie, 31 Vet. App. 243 (2019). However, this does not detract from the value of the study cited in the opinion. The examiner also opined that the Veteran's hyperthyroidism likely did not cause or worsen OSA. The examiner explained that multiple medical papers and research showed a strong link between hyperthyroidism and sleep problems, including "waking up for no specific reason, night sweats, and insomnia to name a few." However, the examiner explained there was "no evidence that hyperthyroidism can cause or contribute to the development of [OSA]," and that while hyperthyroidism and OSA have similar symptoms this does not mean that they are related or that one causes the other. See August 2024 Hyperthyroid Opinion. The examiner's rationale for this opinion is inadequate. As noted above, the examiner's PTSD opinion cited to a study stating that "[t]here is substantial evidence to support the role that disturbed sleep may play in the pathophysiology of OSA." Thus, the examiner's rationale fails to explain why the disturbed sleep caused by hyperthyroidism does not cause OSA. Moreover, the examiner did not explain the effects of sleep impairment from hyperthyroidism in the context of the bidirectional relationship between OSA and PTSD. In this regard, if OSA and PTSD each cause one another and hyperthyroidism causes sleep impairment similar to OSA, this suggests that hyperthyroidism could cause or worsen OSA with PTSD as an intermediate step; however, the examiner's opinions do not address this. Additionally, the examiner opined that the Veteran's gastritis had less likely than not caused or worsened the Veteran's OSA. The examiner noted a possible relationship between gastroesophageal reflux disease (GERD) and OSA, although no definitive connection has been determined. See August 2024 Gastritis Opinion. The examiner went on to explain that this possible relationship was not relevant in this case, as the Veteran did not have GERD. Id. However, this rationale fails to address the evidence showing that acid reflux and pyrosis are symptoms of the Veteran's service-connected gastritis. See, e.g., August 2017 Stomach DBQ. The examiner also provided opinions addressing the effect of some of the medications used to treat the Veteran's service-connected disabilities. The examiner explained that medications do not cause a change in the anatomy of the upper airway, soft palate, pharynx, or tongue. Rather, the examiner explained that these medications, if taken in too high of a dose, would have a sedative effect and be considered Central Sleep Apnea, not OSA. Moreover, this sedative effect would slow down the portion of the brain that controls the breathing rate until it stops. See, e.g., August 2024 Migraine Opinion. In other opinions, the examiner is more specific with respect to the medications being discussed. The specificity in these opinions shows that the examiner's opinions address the effect of pain medications and medications prescribed to treat the Veteran's PTSD and depression symptoms. See August 2024 RLE Radiculopathy Opinion; August 2024 PTSD Opinion. The examiner's opinions addressing the effects of medications are inadequate, as they do not address the effects of therapeutic doses of muscle relaxers used to treat the Veteran's service-connected musculoskeletal disabilities. As noted above, the examiner opined that OSA is caused when muscles in the back of the throat relax too much for proper breathing. See August 2024 Medical Opinion (Direct Service Connection), supra. Yet the examiner inexplicably failed to mention the effect of muscle relaxation when discussing the effect of the Veteran's medications. Although the opinions discussed above are not supported by adequate rationales, it is not necessary that the Board remand this matter to correct these deficiencies, as the evidence supports a full grant of the benefit sought on appeal. In this regard, there is substantial probative evidence linking OSA to the Veteran's service and service-connected disabilities. As noted above, the evidence shows that OSA is caused by relaxed muscles blocking the airway, and the Veteran has been prescribed muscle relaxers for her service-connected disabilities throughout the appeal period. See, e.g., November 2013 Neck Conditions DBQ. Moreover, the evidence shows that OSA is caused by sleep problems, and the Veteran reported sleep problems during service and her service-connected disabilities continue to cause sleep problems. Additionally, the evidence shows that OSA is typically linked to obesity and is primarily seen in males, and the Veteran is female and not obese. Here, the evidence of record weighs in favor of the claim. There is probative evidence showing a relationship between the Veteran's service-connected disabilities and OSA. In particular, the August 2024 examiner relied on evidence of a "bidirectional" relationship between PTSD and OSA. Critically, while there are some adequate opinions of record weighing against a relationship between OSA and particular service-connected disabilities, there is no adequate opinion of record addressing the combined impact of the Veteran's service-connected disabilities. Although there is no formal medical opinion of record linking the Veteran's OSA to the combined impact of her service-connected disabilities, this does not preclude an award of service connection, as the Board has weighed the risk factors and found them in favor of the claim. Moreover, the Veteran has waited patiently for many years while the Board has attempted to fully develop her appeal. See, e.g., Andrews v. McDonough, 34 Vet. App. 216 (2021). Although the Board has had some success in developing probative evidence, it has not obtained fully adequate opinions; however, remanding this matter to do so would not result in any benefit flowing to the Veteran, as the present evidence of record weighs in favor of the claim. Thus, as the evidence shows that the Veteran's OSA was caused by her service-connected disabilities, the third and final element of secondary service connection is met, and the appeal is granted. The AOJ will issue a decision implementing this award of service connection. If the Veteran disagrees with the initial rating or effective date of service connection assigned by the AOJ, she may seek review by filing an appropriate VA form. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Badaczewski, Donald M. The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.