Citation Nr: 1632248 Decision Date: 08/12/16 Archive Date: 08/23/16 DOCKET NO. 09-15 179A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a respiratory disorder, to include bronchitis and to include as an undiagnosed illness under 38 C.F.R. § 3.317. 2. Entitlement to service connection for headaches, to include as an undiagnosed illness under 38 C.F.R. § 3.317. 3. Entitlement to an initial evaluation in excess of 20 percent for fibromyalgia for the period of October 30, 2009 to February 10, 2014, and in excess of 40 percent thereafter, to include an effective date prior to February 11, 2014 for the award of a 40 percent evaluation. 4. Entitlement to an initial evaluation in excess of 10 percent for irritable bowel syndrome (IBS) for the period of October 30 2009 to August 20, 2013, and in excess of 30 percent thereafter, to include an effective date prior to August 21, 2013 for the award of a 30 percent evaluation. 5. Entitlement to an extraschedular evaluation for fibromyalgia. 6. Entitlement to an extraschedular evaluation for IBS. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Peters, Counsel INTRODUCTION The Veteran had active duty service from January to May 1989 and from July to December 1991; during the Veteran's second period of service, she is shown to have service in the Persian Gulf from July to December 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2007, June 2009 and August 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). This case was initially before the Board in May 2013, at which time it was remanded for the Veteran to be scheduled for a Board hearing. The Veteran testified at a Board hearing before one of the undersigned Veterans Law Judges in August 2014. Following that hearing, the Board remanded the case in October 2014 for additional development. This case was last before the Board in January 2016, at which time it was remanded in order for the Veteran to be scheduled for a second Board hearing, which she requested in a December 2015 correspondence. Subsequently, the Veteran testified at a second Board hearing before another of the undersigned Veterans Law Judges in April 2016. During that second hearing and noted in that transcript, the Veteran waived her right to a third hearing before a third Veterans Law Judge. See Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). Accordingly, the Board will proceed with adjudication of the case at this time. Finally, the increased rating claims for fibromyalgia and IBS have been bifurcated into schedular and extraschedular evaluations. See Brambley v. Principi, 17 Vet. App. 20, 24 (2003). The issues of entitlement to TDIU and extraschedular evaluations for fibromyalgia and IBS are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In her April 2016 hearing, the Veteran stated that she wished to withdraw the respiratory and headache claims pending before the Board at that time; she confirmed her wish to withdraw those claims on the record at that hearing, which has been reduced to a written transcript associated with the claims file. 2. Throughout the appeal period, the Veteran's fibromyalgia is manifested by constant or nearly constant widespread musculoskeletal pain with fatigue, and is more closely approximate to a disability that is refractory to therapy. 3. Throughout the appeal period, the Veteran's IBS is manifested by diarrhea, or alternating episodes of diarrhea and constipation, with more or less constant abdominal distress. 4. Although the Veteran had approximately three nighttime fecal incontinence episodes a week for a period of a couple of months as well as some diarrhea-related accidents during the appeal period, the Veteran did not have any daytime episodes of fecal incontinence nor were her diarrhea-related accidents shown to be more closely approximate to a disability picture manifested by extensive leakage and fairly frequent involuntary bowel movements. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeals of the issues of service connection for a respiratory disorder, to include bronchitis, and headaches have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 2. The criteria for establishing a 40 percent evaluation throughout the appeal period for the Veteran's fibromyalgia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, 4.71a, Diagnostic Code 5025 (2015). 3. The criteria for establishing a 30 percent evaluation, but no higher, throughout the appeal period for the Veteran's IBS have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, 4.114, Diagnostic Codes 7319, 7332 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal of Service Connection Claims Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn during the course of a Board hearing or in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202 (2015). Withdrawal may be made by the appellant or by her authorized representative. 38 C.F.R. § 20.204 (2015). In her April 2016 hearing, the Veteran stated that she wished to withdraw the respiratory and headache claims pending before the Board at that time; she confirmed her wish to withdraw those claims on the record at that hearing, which has been reduced to a written transcript associated with the claims file. In light of these statements, the Board finds that there remain no allegations of errors of law or fact for appellate consideration as to those issues. Accordingly, the Board does not have jurisdiction to review those issues, and they are dismissed. Veterans Claims Assistance Act of 2000 (VCAA) The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant VCAA notice was sent to the Veteran in November 2009. Further, regarding the increased rating claims, the Veteran's appeal arises from her disagreement with the initial ratings assigned following the grants of service connection for her fibromyalgia and IBS disabilities. Courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. §3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service, VA, and private treatment records are associated with the claims file. VA provided relevant examinations of the Veteran's fibromyalgia and IBS disabilities most recently in April 2015; those examinations are adequate. Although the Board is remanding for Social Security Administration (SSA) records and VA Vocational Rehabilitation records, as noted in the Remand section below, the Board finds that those records are not relevant to the issues decided herein and therefore finds that proceeding with adjudication is not prejudicial to the Veteran. This is because the SSA records address a period of time prior to the rating period on appeal for the Veteran's IBS and fibromyalgia. Additionally, the Vocational Rehabilitation records would not likely demonstrate symptomatology of those disabilities beyond what is shown in the Veteran's VA treatment records. Moreover, to the extent that such records might be relevant to determining the occupational impairment stemming from the Veteran's IBS and fibromyalgia, the matters of entitlement to extraschedular ratings for these disabilities has been deferred pending the development ordered in the remand below. The Board also acknowledges that this case was the subject of a Board remand in October 2014. That remand instructed that the Veteran be afforded, in pertinent part, VA examinations for her IBS and fibromyalgia disabilities; such was accomplished in April 2015. Therefore, the Board finds that its remand order has been substantially complied with, and it may proceed to adjudicate upon the merits of this case. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Analysis of Increased Evaluation Claims for Fibromyalgia and IBS Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2015); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2015); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2015); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2015). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 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 may be due to pain, supported by adequate pathology and evidenced by 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 disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2015); see also 38 C.F.R. § 4.45 (2015). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Fibromyalgia Claim The Veteran filed her claim for service connection for fibromyalgia on October 30, 2009. Service connection for fibromyalgia was awarded in an August 2010 rating decision, at which time it was assigned a 20 percent evaluation, effective October 30, 2009. During the pendency of the appeal, the Veteran's fibromyalgia was increased to 40 percent disabling, effective February 11, 2014, in a September 2015 rating decision. Throughout the appeal period, the Veteran's evaluations for fibromyalgia have been assigned under Diagnostic Code 5025. Under Diagnostic Code 5025, fibromyalgia is defined as widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms. See 38 C.F.R. § 4.71a, Diagnostic Code 5025 (2015. Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. See Id., Note. A 10 percent evaluation is warranted for symptoms that require continuous medication for control. A 20 percent rating is warranted for symptoms that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. A 40 percent evaluation is warranted for symptoms that are constant, or nearly so, and refractory to therapy. See Id. "Refractory" means resistant to treatment or cure; unresponsive to stimulus; or not responding to an infectious agent. See Merriam-Webster Medical Dictionary, available at http://c.merriam-webster.com/medlineplus/refractory (2016). The Veteran's fibromyalgia has been assigned the highest possible evaluation for the period beginning February 11, 2014; the Board will therefore no longer address the schedular criteria respecting that period. This case will therefore focus on the period prior to February 11, 2014. In several recent statements and during the most recent April 2016 hearing, the Veteran argued that the effective date assigned for her 40 percent evaluation should be the date she was awarded service connection. The Board notes that determining whether at an earlier effective date is warranted for assignment of a higher rating is essentially the same type of analysis as a claim for increased evaluation for that particular period as both focus on when it was factually ascertainable that an increase in severity of the disability occurred. Accordingly, the Board will analyze that issue as a claim for increase for the period prior to February 11, 2014. Throughout the appeal period, the Veteran has consistently argued that the severity of her symptomatology has been consistent and is severe in nature. Specifically, throughout her statements during the appeal period, she asserts that her fibromyalgia is constant and severe. In her hearings, the Veteran has indicated that she has widespread pain, including in her shoulders, elbows and hips, which is constant even with use of medication. Turning to the evidence of record, in a January 2009 VA Rheumatology record, the Veteran reported having polyarthralgias, joint stiffness and sharp pain for several years; she indicated that she has pain in her neck, shoulders, lower and midback, hands and wrists. Her pains were jabbing and sharp; she also reported that the pain worsened as the day went on. After physical examination, the examiner noted that the Veteran had arthralgias and myalgias in the shoulders, knees, neck, and low back, as well as myalgias in the upper and lower extremities. Hydromorphone and ibuprofen did not help. She had stiffness in her shoulders in the morning and in the low back for a few hours. Her examination showed multiple trigger points compatible with diffuse myofascial pain; she had not yet started amitryptiline. In a June 2009 VA treatment record, the Veteran reported shoulder, head, and back, as well as generalized body pain, described as aching, dull, throbbing, numbness, tightness, sore, burning and pressure. She has had this pain for 3 years, which was worse with lifting, standing, stress, walking or cold/damp weather. She was helped by rest and medications. She was treating her pain with capsaicin cream and methocarbamol, which reduced her pain by 50 percent. On examination, the Veteran's lumbar and bilateral shoulders had full range of motion and were nontender to palpitation. She was diagnosed with fibromyalgia. The Veteran reported that her medication for fibromyalgia, Meloxicam, was not helping in a January 2010 VA Women's Health treatment record. In another January 2010 VA treatment record, the Veteran again reported general joint pain which was worse and also muscle pain, headaches, and lower back, leg, shoulder, and upper back pain. She described the pain and aggravating and alleviating factors as above. She was taking Mobic, capsaicin cream and lidocaine gel for her pain at that time. Again, on examination, she had full range of motion of her lumbar spine and bilateral shoulders, which were nontender to palpitation. She was diagnosed with fibromyalgia and chronic pain syndrome. The Veteran underwent a VA fibromyalgia examination in May 2010. At that time, the Veteran reported she was diagnosed with fibromyalgia in February 2009 and that she had gotten progressively worse over the last year. The examiner listed an extensive medication list that the Veteran was taking for her pain. The examiner noted that continuous medication was required for control of her fibromyalgia. The Veteran reported that she had symptoms of fibromyalgia, including unexplained fatigue, sleep disturbance, paresthesias, headache, alternating diarrhea and constipation, abdominal cramps, abdominal bloating, depression, anxiety and musculoskeletal symptoms, which included: widespread musculoskeletal pain, stiffness, achiness, myalgia, and arthralgia. Her pain was located in her neck, bilateral arms, bilateral legs, back, chest, and the Veteran reported that she had "pain from [her] head to [her] toes." The Veteran reported these symptoms were constant or nearly so. The Veteran's symptoms were exacerbated by emotional stress, time of day (worse in the morning), cold or damp weather, insufficient sleep and overexertion. Her symptoms were alleviated by a warm bath, stretching and medications. The Veteran reported pain on both the right and left sides, above and below the waist, as well as the axial skeleton and extremities. On examination, the Veteran had right and left sided tender points at several points all over her body. The examiner diagnosed the Veteran with fibromyalgia syndrome. The Veteran did not have lost time from work due to her fibromyalgia, although there were significant effects on her occupation, including lack of stamina, weakness or fatigue, and pain, which resulted in her needing to be assigned different duties. The examiner noted that the Veteran's fibromyalgia prevented her from participating in sports, mildly affected her ability to do chores, shop and recreation, and moderately impacted her ability to exercise and travel; she was not impacted in her ability to feed, bathe, dress, toilet, or groom herself. The Veteran again sought VA treatment in August 2010, at which time she reported fatigue, joint and muscle pain that had worsened over the last 6 months. She reported that if she did normal housework, she was fatigued for the rest of the day; she reported that she must take naps daily, although she does not feel rested afterwards. She felt totally drained; she did not feel rested after nighttime sleep and did not sleep soundly due to her pain. She reported that this interfered with her daily life. She reported having muscle and joint pain "all over," including in her ribs, for several years. On examination, she was tender diffusely to palpitation of the upper and lower extremities, back and neck. She was diagnosed with insomnia/fatigue/polyarthralgias/daytime somnolence. In another September 2010 VA Rheumatology treatment record, the Veteran reported that her polyarthralgias were getting worse, that they were constant and that she hurt all over, with 10 out of 10 pain. She reported that she had a chronic frontal headache; neck, shoulder, low back, lower ribcage, knee, and ankle pain; and, soreness. She felt symptoms in both her muscles and joints. She reported her pain was worse in the morning and with activity; morning stiffness reportedly lasted 3 hours. Her symptoms had worsened over the past few years and she was fatigued. She also reported having minimal improvement with Gabapentin. She denied joint swelling, rashes, psoriasis, hair loss, history of uveitis, oral ulcers, chronic cough or hemoptysis. After physical examination, which indicated several tender and trigger points throughout her body, the examiner diagnosed the Veteran with fibromyalgia; the examiner noted that the Veteran had "multiple tenderpoints consistent with fibromyalgia . . . she does not have evidence of inflammatory arthritis." The Veteran was again treated by VA Rheumatology in January 2011, at which time the Veteran reported that her Gabapentin was not helping. She again reported constant joint pain diffusely; her reported symptoms, physical examination, and the examiner's conclusions were substantially similar to those noted above. In a February 2011 VA pain management record, the Veteran was noted as having fibromyalgia and on examination noted tenderness throughout her body. The Veteran's medications were continued at that time and the Veteran was informed that she should increase her activity level, including chores, exercise and gardening. She was also seen in May 2011 with complaints of pain all over, although it was more prominent in one thigh at that time. She was diagnosed with generalized pain at that time. In another May 2011 Women's VA treatment record, the Veteran reported a flare up of severe pain that began a week prior for no apparent reason; she reported that she hurt all over and was having 10 out of 10 pain, muscle spasms, and aching and stabbing. She felt exhausted and was having problems concentrating and with her memory, although that had been a chronic problem for her before. She was referred at that time to the Washington, DC VA War Related Illness and Injury Study Center (WRIISC) at that time; she participated in treatment at that facility in August 2011, and the Board has reviewed those records. Respecting the Veteran's fibromyalgia, which was not a focus during her treatment at that facility, her complaints were substantially similar to those described above. The Veteran was again seen in January 2012 by VA Women's Health Care with reports of increased myofascial pain in her upper and lower back, shoulders, elbows, fingers, knees, and hips; she reported she had pain and her feet felt puffy when walking. Her legs felt weak, gave out and she was having leg spasms. She was fatigued, and unable to tolerate exercise due to her pain and fatigue. She reported that this felt like her normal pain exacerbation episodes, although it was lingering. The Veteran was seen for a history and physical in April 2012, with similar complaints above; the examiner noted that she was rocking back and forth in pain and wincing frequently during the examination; she had diffuse body aches and tenderness when touched almost anywhere on her body. Treatment records in April 2013 were similar in both the Veteran's reported symptoms and physical examination. Also, in September 2013, the Veteran's VA Rheumatology examination was substantially similar in reported symptoms and physical examination to that noted above. In a February 11, 2014 treatment record, the Veteran reported pain in her shoulders, elbows, and lower back from her fibromyalgia flareup; she reported her pain was constant and worse at night. She was diagnosed with a fibromyalgia exacerbation. Finally, the Veteran underwent a VA fibromyalgia examination in April 2015. At that time, the Veteran reported that her fibromyalgia was worse since her last VA examination; she felt that she had daily, ongoing, nonstop achy pain in her shoulders, elbows, knees, hips, hands and lower back. She was taking medication which did not help. Her pain bothered her when she slept and she found herself massaging her body. She stated her ribcage was tender and reported muscle spasms in her lower extremities. She reported using a TENS unit and heating pad, as well as continuing to take medication daily and pain-relieving cream as needed. The examiner noted that the Veteran required medication continuously for control of her symptoms. The examiner, however, noted that the Veteran was not seeking treatment at that time and was not refractory to therapy. On examination, the Veteran had constant or nearly constant musculoskeletal pain in her low cervical region, occiput, trapezius muscle, lateral epicondyle, greater trochanter, and medial knee joint line, all bilaterally. The examiner noted that the Veteran felt that her fibromyalgia impacted her ability to work because she felt "she would be irritable and moody if she worked." The examiner further noted that the Veteran's subjective complaints of widespread musculoskeletal pain were not reliable for ratings purposes, as she had multi-joint degenerative changes of the neck, back, ankles and knees, that could easily account for her claimed fibromyalgia symptoms; the examiner noted 2013 and 2014 VA x-rays of the Veteran's lumbar spine, cervical spine and bilateral knees. The examiner also concluded that the Veteran was diagnosed with sleep apnea, which could also easily account for her claimed sleep disturbance secondary to fibromyalgia. Based on the foregoing evidence, the Board finds that a 40 percent evaluation throughout the appeal period is warranted. Specifically, throughout the appeal period prior to February 11, 2014, the Veteran complained consistently and repeatedly of severe widespread musculoskeletal pain with associated fatigue. The Veteran reported and sought treatment for her daily and constant symptoms, which significantly impacted her activities of daily living. The Veteran also repeatedly reported that her medication was not helping. Moreover, the Board cannot find a discernible difference or increase in symptomatology respecting her fibromyalgia that occurred on February 11, 2014; rather, the symptoms described at that time appear to be substantially similar to the consistent and repeated complaints noted from 2009 until that time. Consequently, the Board must conclude that the Veteran's fibromyalgia, which is characterized throughout the appeal period as widespread musculoskeletal pain with fatigue, is shown to be constant. Additionally, given the Veteran's repeated complaints that her medications were not helping and the multiple different changes in medication regimens noted throughout the appeal period, the Board must conclude that the disability picture demonstrated prior to February 11, 2014, is more closely approximate to a fibromyalgia disability that was refractory to treatment. Accordingly, a 40 percent evaluation-which is the highest possible evaluation under the Rating Schedule-for the Veteran's fibromyalgia is warranted throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5025. IBS Claim The Veteran filed her claim for service connection for IBS on October 30, 2009. Service connection for IBS was awarded in an August 2010 rating decision, at which time it was assigned a 10 percent evaluation, effective October 30, 2009. During the pendency of the appeal, the Veteran's IBS was increased to 30 percent disabling, effective August 21, 2013, in a June 2015 rating decision. Throughout the appeal period, the Veteran's evaluations for IBS have been assigned under Diagnostic Code 7319. Under Diagnostic Code 7319, for irritable colon syndrome (spastic colitis, mucous colitis, etc.), a noncompensable evaluation is warranted for mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is warranted for moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress. A 30 percent evaluation is warranted for severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. See 38 C.F.R. § 4.114, Diagnostic Code 7319 (2015). With regard to coexisting abdominal conditions, VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113 (2015). Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See Id. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. See 38 C.F.R. § 4.114. The Board also notes that, with regard to the schedule of ratings for the digestive system, 38 C.F.R. § 4.114 expressly prohibits, in pertinent part, the combination of ratings under Diagnostic Codes 7301 to 7329, inclusive, which include the schedular criteria for irritable colon syndrome (Diagnostic Code 7319). The Veteran's IBS has been assigned the highest possible schedular evaluation for the period beginning August 21, 2013; the Board will therefore focus on the period prior to August 21, 2013. Additionally, in several recent statements and during the most recent April 2016 hearing, the Veteran argued that the effective date assigned for her 30 percent evaluation should be the date she was awarded service connection. As noted above, the issue of an earlier effective date for the award of a higher rating is essentially the same type of analysis as a claim for an increased evaluation for that particular period. Accordingly, the Board will analyze the issue as a claim for an increased evaluation for the period prior to August 21, 2013. Throughout the appeal period, the Veteran has repeatedly contended that the severity of her IBS symptomatology has been consistent and is severe in nature. Specifically, throughout her statements during the appeal period, she asserts that she had weekly bouts of alternating diarrhea and constipation, as well as fecal incontinence, bloating, and abdominal pain and gas; particularly, the Veteran has indicated that she fears being too far away from a bathroom in case she has an "accident" due to her diarrhea, which causes embarrassment. Finally, she also noted that when she first was diagnosed with IBS, she lost weight and was dehydrated. Turning to the evidence of record, the Veteran had a VA history and physical examination in July 2008, at which time she reported having abdominal pain, described as relapsing and remitting abdominal cramps, and diarrhea. After examination, the examiner noted that the Veteran's symptoms were most likely viral gastroenteritis due to sick contact with her husband. However, in January 2009, the Veteran was seen by VA Gastroenterology for complaints of diarrhea; she reported 3-4 loose, nonbloody stools a day, with alternating periods of constipation, with 1-3 days without a bowel movement. She also described a sensation of incomplete evacuation and abdominal bloating; bowel movements made her abdominal pain better. She denied nausea and vomiting, weight loss, or change in appetite at that time. On examination, the Veteran denied any dysphagia or gastroesophageal reflux disease (GERD) symptoms; she did not have any anemia and her stool samples were negative, although she had elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The Veteran was diagnosed with diarrhea alternating with constipation, which likely represented IBS. In an October 2009 Women's Health Care VA record, the Veteran reported that she started having diarrhea at least three times a day five days prior; she reported it was constant and has lasted for a week. She also reported a decreased appetite, decreased fluid intake, and feeling weak. She also reported abdominal cramps, which were 6 out of 10 and felt like past flare-ups of her IBS. She had nausea, but denied vomiting or fevers. She also had trouble urinating with the onset of her diarrhea. She was diagnosed with acute diarrhea, which was a probable IBS exacerbation. The Veteran was again seen by VA Gastroenterology in January 2010, at which time she had complaints of chronic diarrhea alternating with constipation. She reported her diarrhea was every other day and that she takes one dose of Benefiber a day. She reported that her symptoms have been ongoing for 5 years and that she carried a diagnosis of IBS. She also took Hyoscyamine for abdominal cramps, which was somewhat helpful. She denied weight loss, nausea, vomiting, or changes in appetite. She was diagnosed with IBS and told to take fiber three times a day. In May 2010, the Veteran underwent a VA examination of her IBS. The Veteran reported symptoms similar to those noted above at that time; the examiner noted an extensive list of medications that she was taking for her gastrointestinal problems. The Veteran denied a history of intestinal neoplasm, history of nausea, history of vomiting, a history of fistula, or a history of ulcerative colitis; however, she reported having monthly constipation; less than weekly/episodic diarrhea, which lasted 1-2 days and that she had 8-12 attacks a year; suprapubic intestinal pain, described as colicky and crampy, which was daily, severe and lasted 30 minutes; bloating; and, alternating diarrhea and constipation. The examiner noted that the Veteran's episodes of symptoms were not consistent with a partial bowel obstruction. On examination, the Veteran's overall health was good; there was no significant weight loss or malnutrition, anemia, fistula, or abdominal mass. There was mild tenderness to palpitation in her lower right quadrant. The examiner diagnosed the Veteran with IBS and noted that there were no significant effects on her occupational functioning. However, there was mild effect on her ability to exercise, travel, toilet, and participate in recreation, and a moderate effect on her ability to participate in sports; there was no effect, however, on her ability to do chores, shop, feed, bathe, dress or groom herself. The Veteran followed up with VA Gastroenterology in May 2010. Her complaints had not changed at that time; she reported chronic diarrhea with alternating constipation. She had not increased her fiber intake as previously instructed. She was diagnosed with IBS and told again to increase her fiber intake to three times a day. The Veteran participated in a Persian Gulf War Registry examination in December 2010, at which time she reported that she had begun having episodes of fecal incontinence. The Veteran subsequently sought private treatment for her fecal incontinence with Dr. J.M. in March 2011. At that time, she reported having fecal incontinence while she was sleeping for a couple of months; such episodes would occur three times a week while she was sleeping. However, beginning in October 2010, there was no more incontinence and the pressure would wake her up and she would have a bowel movement. She denied any fecal incontinence during the daytime at that time. She also reported having IBS with alternating diarrhea and constipation, although most of the time she had diarrhea. She also reported having abdominal pains sometimes, which come and go; her pain was better after bowel movements. She denied melena, hematochezia, or a family history of colon cancer. She reported a colonoscopy two years prior was normal. After examination, Dr. J.M. diagnosed the Veteran with IBS with diarrhea and a normal colonoscopy two years ago, as well as fecal incontinence although there had been no complaints of fecal incontinence since October 2010. In an August 2011 VA neurology history and physical, the Veteran reported the same history and complaints regarding IBS and fecal incontinence as reported to Dr. J.M., detailed above. In May 2013, the Veteran stated as follows respecting her IBS: For the past six months I have been experiencing an increase in diarrhea. It interferes with my quality of life and socializing to the point I am hesitant to go out in public unless I am absolutely sure bathrooms are accessible. My stomach cramps, I am always bloated along with having gas on a daily basis and at night which not only uncomfortable but embarrassing as well. I am taking my medications as prescribed and I also have weight loss. I am currently 131 [pounds] down from 168 [pounds] a year ago. She requested a medical appointment and was seen by VA Gastroenterology in June 2013; the examiner noted that the Veteran had the same symptoms at that time "that she has always had" since 2009, which included bloating, cramping, and loose to watery stools 4-5 times a day. She also had unintentional weight loss due to reducing what she ate; she lost 20 pounds in the past year. The examiner also noted that a 2009 colonoscopy was unremarkable. The examiner diagnosed the Veteran with longstanding IBS, diarrhea predominant; "she has been withholding food to prevent 'accidents' and has lost 20 pounds in the last year." On August 21, 2013, the Veteran was seen by VA, again with complaints of non-specific crampy abdominal pain, bloating, alternating diarrhea and constipation. She also initially had unintentional weight loss due to withholding meals for fear of a diarrhea-related accident; however, she was eating better and her weight had stabilized. Her pain had improved after starting lactobacillus, a probiotic; she was also taking hyoscyamine for cramping. With regards to bowel movements, there are days that she goes continuously, and her bowel movements are usually loose but occasionally watery, nonbloody, and without melena. She takes three loperamide pills a day. Other times she skips a day or two without any bowel movements. The Veteran was diagnosed with longstanding IBS, diarrhea predominant, and stabilized weight loss for six months, after initially withholding meals due to diarrhea. Finally, the Veteran underwent a VA examination of her IBS in April 2015. She reported having diarrhea on average 8-10 times a day and a soft stool on average twice a day; she reported having constipation twice a month. After two days of constipation, she will start taking her docusate and will continue taking that medication for approximately two more days until she has a bowel movement; she increases her fluid intake during that period. She notices increased stomach pressure/distention and being gassy during her bout of constipation. She felt like she has an "urge" daily. She took lactobacillus and lopiramate daily, and has increased her fiber intake in her diet. She reported that she was able to go out to movies and restaurants, although there are more days when she stays home than when she goes out. Recently, she began noticing a mucosy substance on her toilet paper after a loose bowel movement. The examiner noted that the Veteran needed continuous medication for her IBS, which included lactobacillus granules and diphenoxylate daily, and docusate as needed. On examination, the examiner noted the Veteran had frequent episodes of bowel disturbance with abdominal distress. She did not have any weight loss, malnutrition, or any other serious complications or health effects due to her IBS. The examiner noted that the Veteran's IBS impacted her employment by necessitating that she be near a restroom. Based on the foregoing evidence, the Board finds that a 30 percent evaluation throughout the appeal period is warranted. Specifically, the evidence demonstrates that the Veteran has IBS with diarrhea predominantly, although she has episodes of alternating diarrhea and constipation. The Veteran also takes daily medication in order aid her abdominal pain, distention and bloating. Additionally, the Veteran had, during the appeal period, episodes of nighttime fecal incontinence, as well as unintentional weight loss because she was missing meals due to a fear of diarrhea-related accidents. Based the totality of the disability picture presented, the Board finds that the Veteran's symptoms more closely approximate to more or less constant abdominal distress throughout the appeal period. Moreover, the Board cannot find a discernible difference or increase in symptomatology that occurred on August 21, 2013; rather, the symptoms described at that time appear to be substantially similar to the consistent and repeated complaints noted from 2009 until that time. This finding is significantly bolstered by the June 2013 examiner findings that her complaints at that time were the same complaints she has always had. As a final matter, the Board notes that it has also considered whether an evaluation under Diagnostic Code 7332 is more appropriate in this case or would allow for the award of an evaluation in excess of 30 percent, at any time throughout the appeal period, including subsequent to August 21, 2013. However, the evidence of record does not demonstrate extensive leakage and fairly frequent involuntary bowel movements in this case. While the Board notes that the Veteran had nighttime fecal incontinence, such appeared to only occur at most three times a week for a couple of months, ending in October 2010; the time period during which these episodes of fecal incontinence are not specifically described by the evidence of record. Moreover, the Veteran's fecal incontinence only occurred during the night and she never had any daytime episodes of fecal incontinence. Additionally, while the Veteran had a fear of and in fact had some diarrhea-related accidents during the appeal period, such does not appear to be a frequent occurrence during the appeal period. Consequently, in the Board's opinion, the disability picture in this case more closely approximates occasional involuntary bowel movements which necessitate wearing a pad rather than extensive leakage and fairly frequent involuntary bowel movements. Such commensurates to only a 30 percent evaluation under Diagnostic Code 7332, which is not higher than the evaluation assigned under Diagnostic Code 7319 at any time during the appeal period, discussed above. See 38 C.F.R. § 4.114, Diagnostic Code 7332 (2015). In short, throughout the appeal period, the Board finds that the Veteran's IBS is manifested by diarrhea, or alternating episodes of diarrhea and constipation, with more or less constant abdominal distress. Accordingly, a 30 percent evaluation is awarded throughout the appeal period for the Veteran's IBS. See 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7319. ORDER The appeal as to the issue of service connection for a respiratory disorder, to include bronchitis, is dismissed. The appeal as to the issue of service connection for headaches is dismissed. A 40 percent evaluation, but no higher, for fibromyalgia is granted throughout the appeal period. A 30 percent evaluation, but no higher, for IBS is granted throughout the appeal period. REMAND With regards to the Veteran's TDIU claim, the Veteran testified in her April 2016 hearing that she had participated in VA's Vocational Rehabilitation program. She submitted a September 2015 letter from the St. Petersburg RO Vocational Rehabilitation and Employment Office, however, the complete records from the Veteran's VA Vocational Rehabilitation participation do not appear to have been associated with the claims file. Accordingly, the Board must remand in order for those records to be obtained and associated with the claims file. See 38 U.S.C.A. §5103A(b), (c); 38 C.F.R. § 3.159(b). Additionally, the Veteran testified that she applied for Social Security Administration disability benefits in 2008, although her claim was denied. It appears that VA requested those records from the Social Security Administration (SSA) in August 2008. SSA replied that it was unable to locate the medical file in an August 2008 response. It does not appear that any follow-up with SSA was completed to see if those records had been located or whether further attempts to obtain those records would be futile. Given the need to remand for the VA Vocational Rehabilitation records, above, on remand, the AOJ should additionally attempt to obtain the Veteran's identified SSA records as it is not clear from the record that further attempts to obtain the records would be futile. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). Finally, in situations where entitlement to an extraschedular rating or a TDIU arises in connection with an appeal for an increased rating, the Board is not precluded from issuing a final decision on the increased rating claim and remanding the extraschedular-rating and/or TDIU-rating issues to the RO. Brambley v. Principi, 17 Vet. App. 20, 24 (2003). Here, the Veteran's increased ratings claims for fibromyalgia and IBS are each bifurcated into one part that is a schedular evaluation of the rating (discussed and decided above) and a second part that deals with an extraschedular evaluation of the same and a TDIU. The claim for TDIU must be remanded for the reasons noted above. As development of the TDIU claim may impact the extraschedular ratings, they are remanded as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Obtain all of the Veteran's VA Vocational Rehabilitation records and associate those documents with the claims file. 2. Obtain from the Social Security Administration, or other state agency administering disability benefits, the records pertinent to the Veteran's claim for disability benefits as well as the medical records relied upon in considering that claim. if it is determined that additional research requests would be futile, this must be documented in the file. 3. Following any additional indicated development, the AOJ should review the claims file and readjudicate the claims. If the benefits sought on appeal remain denied, the Veteran should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________ ______________________________ K. PARAKKAL JAMES L. MARCH Veterans Law Judge, Veterans Law Judge, Board of Veterans' Appeals Board of Veterans' Appeals ____________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs