Citation Nr: 9834209 Decision Date: 11/19/98 Archive Date: 11/24/98 DOCKET NO. 92-52 759 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased rating for focal inflammatory myopathy of the left lower extremity currently rated as 60 percent disabling. 2. Entitlement to an increased rating for focal inflammatory myopathy of the left upper extremity currently rated as 20 percent disabling. 3. Entitlement to an increased rating for focal inflammatory myopathy with carpal tunnel syndrome of the right upper extremity currently rated as 40 percent disabling. 4. Entitlement to an increased rating for focal inflammatory myopathy of the right lower extremity currently rated as 10 percent disabling. 5. Entitlement to an increased rating for major depression with psychotic features. currently rated as 50 percent disabling. 6. Entitlement to financial assistance in acquiring specially adapted housing or special home adaptations. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The appellant, her mother and her sister ATTORNEY FOR THE BOARD Terence D. Harrigan, Counsel INTRODUCTION The veteran had active military service from September 1983 to August 1988. This case came before the Board of Veterans' Appeals (Board) on appeal from a decision of the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA). The case was remanded by the Board in September 1994 to obtain additional evidence. It is now before the Board for further appellate review. On a Statement in Support of Claim dated in February 1990 the appellant claimed entitlement to an earlier effective date of payment of compensation benefits based on a total disability rating. The RO did not address that issue and it is not before the Board on appeal at this time. The issue is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that her myopathy/polymyositis of the upper and lower left extremities should be rated as 100 percent disabling. She asserts that she also has dysthymic disorder, impairment of the right upper extremity, and impairment of the right lower extremity which should be rated separate from myopathy/polymyositis. She states that doctors cannot determine the diagnosis of her condition and that she has to take therapy three days a week and take several medications to be able to function. She asserts that she has depression caused by her illness. She contends that she needs specially adapted housing in order to attempt to live a normal life. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on a review of the relevant evidence, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran’s claims for increased ratings for focal inflammatory myopathy of the left lower extremity and the right lower extremity, and for major depression with psychotic features and also against the claim for entitlement to financial assistance in acquiring specially adapted housing or special home adaptations. It is further the decision of the Board that the evidence supports the grant of a 30 percent rating for focal inflammatory myopathy of the left upper extremity and of a separate 30 percent rating for focal inflammatory myopathy with carpal tunnel syndrome of the right upper extremity in addition to the 40 percent rating currently in effect. FINDINGS OF FACT 1. The veteran has focal inflammatory myopathy of the left lower extremity manifested by atrophy of the muscles of the left lower extremity with some weakness of the muscles involved, tenderness of the muscles, pain on most movements of the left lower extremity and a limp on the left side. 2. The veteran has focal inflammatory myopathy of the right lower extremity manifested by tenderness in the knee and pain on motion of the hip, but, otherwise, fairly normal function. 3. The veteran has focal inflammatory myopathy of the left upper extremity manifested primarily by weakness of the deltoid muscle and limitation of motion of the shoulder. 4. The veteran has focal inflammatory myopathy of the right upper extremity manifested primarily by limitation of motion of the right wrist and tenderness of the elbow and shoulder with synovial thickening in, and limitation of motion of, the shoulder as well as by only pincher grasp in the right hand. 5. The veteran has major depression with psychotic features manifested by depression, insomnia, feelings of worthlessness, difficulty concentrating and occasional hallucinations. 6. The veteran does not have loss or loss of use of a lower extremity or of both hands or blindness. CONCLUSIONS OF LAW 1. An increased rating for focal inflammatory myopathy of the left lower extremity is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.124a Code 8620 (1998). 2. An increased rating for focal inflammatory myopathy of the right lower extremity is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.124a Code 8620 (1998). 3. A 30 percent rating is warranted for focal inflammatory myopathy of the left upper extremity. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.124a Code 8613 (1998). 4. A separate 30 percent rating based on median impairment is warranted for focal inflammatory myopathy of the right upper extremity with carpal tunnel syndrome in addition to the 40 percent rating currently in effect for that disability. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.124a Code 8613, 8515 (1998). 5. An increased rating for major depression with psychotic features is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.132 Code 9207 (1996), 4.130 Code 9434 (1998). 6. The criteria for entitlement to financial assistance in acquiring specially adapted housing or in acquiring special home adaptations are not met. 38 U.S.C.A. § 2101 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.809, 3.809a (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background A Medical Board report dated in May 1988 reveals that the veteran began having progressive left leg atrophy starting in December 1986. It began with burning pain from the left knee down to the foot and a dead sensation in the first and second toes. She developed progressive atrophy in the left leg, most notably in the thigh. There was no upper leg, hip or back pain or injury. There were no symptoms in the right leg, either arm, the trunk or cranial areas. An earlier EMG, myelogram and MRI of the spinal area were all negative. General physical examination was within normal limits. Sensory examination was normal except for a deficit related to a past neurectomy in the left foot. Muscle strength and girth were normal in the upper extremities and in the right leg. Atrophy was easily noted in the left leg and hip, most prominently in the left hip and quadriceps. There was moderate decrease in strength of the left hip girdle and quadriceps and mild loss of strength in the more distal muscles of the leg. The right thigh measured 52.8 cm. as compared to 47.5 cm. on the left. The right calf measured 34.0 cm. as compared to 30.2 cm. on the left. Right ankle jerk was 2+ on the right and 1+ on the left. Plantar responses were down going on the right and neutral on the left. Serum CPK was elevated at 219 with normal range being 20-170. Laboratory tests were otherwise negative. Nerve conduction studies of the left leg were normal. EMG revealed denervational potentials in all left leg muscles tested, with moderate decrease in the recruitment pattern throughout. Signs of chronic denervation and reinnervation were seen, such as polyphasic motor unit potentials. The left and right lumbosacral paraspinous muscles revealed 1-2+ denervational potentials. The thoracic paraspinous muscles also showed denervation. Muscles of the right arm were normal except the deltoid which showed several units with satellite units and 1-2+ polyphasic waves in the extensor digitorum communis muscle. The left and right cervical paraspinous muscles showed denervation potentials. The EMG test was interpreted as showing a diffuse denervating process, probably at the anterior horn cell level with no evidence of peripheral nerve involvement. Muscle biopsy showed myopathic features as well as focal inflammation consistent with a diagnosis of inflammatory muscle disease. It was noted that the veteran was able to ambulate, but with left leg pain on ambulation and weight bearing. In a report dated in November 1988, S. H. Subramony, M.D., stated that measurement of the veteran’s calf and thigh showed greater atrophy than reported in January of that year. She had hyperpigmentation of the skin over her back. In December 1988 Dr. Subramony reported that the veteran had started steroid treatment. On VA examination in February 1989, the veteran complained of pain in the left leg from the back into the buttock and thigh all the way down into the foot. The pain was mainly in the muscles and was associated with muscle cramps, weakness, fatigability and progressive loss of muscle mass in the left lower extremity. Neurologic examination of the extremities and neuromuscular system revealed that the upper extremities were normal in appearance, muscle bulk and tone and strength. The left thigh and calf were markedly atrophied compared to the right, but there were no fasciculations or abnormal movements detectable. The veteran’s muscles were all tender and sore to palpation in the left lower extremity from the buttocks down. Muscle strength in the left lower extremity was only slightly decreased compared to the right, but full exertion of the muscles was impossible because of the severe pain and tenderness in them. Strength in the left lower extremity was estimated to be 80 percent of normal. There was no involvement of the right lower extremity. Deep tendon reflexes were present and equal in the lower extremities. She walked with a limp protecting the left lower extremity. The impression was myositis of the left lower extremity, progressive, cause unknown. The veteran, her mother and her sister testified at a hearing before a hearing officer at the RO in May 1989. The appellant stated that she could not sit for long periods of time and that she walked with a limp. She described her symptoms and the side effects of steroid medication that she took. VA out-patient clinic records dated from March to July 1989 reveal that the veteran began receiving treatment at a mental health clinic because of depression. She reported difficulty sleeping. Her mood and affect were depressed. She stated that she coped by pushing herself to be active. On VA examination in August 1989 the veteran complained of severe weakness and pain in the entire left side of the body including the back, buttock, hip, thigh, calf, knee and foot, pain on the right side of the body starting in the right knee, calf and foot, left foot numbness, depression and insomnia. On orthopedic examination she reported that her low back pain was constant, but varied in intensity. Aggravating factors included activities such as bending, lifting or stooping. Prolonged sitting or standing was painful. The pain radiated into the leg and there was numbness and tingling in the left foot. She reported constant pain in the right knee, worsened by weight bearing. Examination revealed that she walked with a mild limp on the left. She was able to stand erect and there was no evidence of paravertebral muscle spasm. There was generalized tenderness to palpation. Range of motion of the lumbar spine was from 60 degrees flexion to 20 degrees extension. Range of motion of the right knee was from 0 degrees to 140 degrees. There was no redness, heat or swelling. There was generalized tenderness to palpation. There was no evidence of instability of the knee. Range of motion of the left ankle was from 10 degrees dorsiflexion to 45 degrees plantar flexion. There was generalized decreased sensation to pin prick over the dorsum of the left foot. Straight leg raising was negative. She could not walk on the heel or toe on the left. She could squat only halfway down and rose bearing most of her weight on the right leg. There was some muscle weakness and atrophy of the left lower extremity. X-rays of the lumbar spine and right knee were within normal limits. The impression included chronic low back pain and chronic right knee pain secondary to overuse syndrome. On neurologic examination the examiner, who had previously examined the veteran, reported that the veteran had a neuropathy, the cause of which had never been elucidated. The examiner noted that specialists could not agree as to how much of her difficulty was due to problems with the nerves and with the muscles or with both. He stated that she had not responded to conventional therapy and that she was gradually getting weaker in all four extremities, with the left lower extremity being most affected. Recently the left upper extremity had begun to get weak and she had pain in all four extremities on movement. She also had developed loss of feeling in the left lower extremity. Examination revealed that she had a mock atrophy of the left lower extremity, both proximally and distally which was much more severe than when the examiner had previously seen her. She was also beginning to have mild, diffuse atrophy of the left upper extremity. She had severe pain and some limitation of motion of all muscle groups. The muscles were tender to palpation. She was unable to exert her strength fully. At best strength was III/V in the left lower extremity, IV/V in the left upper extremity and a little better than IV/V in the right upper and lower extremities. There was blunting of all sensory modalities in the left lower extremity compared to the right. Sensation was normal in the upper extremities. Coordination on the right was intact. Coordination on the left was difficult to test because of limitation of motion and weakness. Her gait was hesitant with drop foot and circumduction of the left leg. She walked very slowly and complained of severe pain in her joints when she moved. Deep tendon reflexes were all present and somewhat brisk. The impression was progressive neuromuscular disorder, with the precise etiology not known. On psychiatric examination the veteran complained that she was irritable, had difficulty sleeping and did not like to be around people. She reported that a telephone ringing made her nervous and that she could not remember the thread of a conversation. Examination revealed that she sat somewhat slumped in a chair. Eye contact was sporadic. There was mild psychomotor retardation. Speech was mildly slurred. Mood was depressed. Affect was restricted. She was precisely oriented to person, place situation and time. Remote, recent and immediate recall were good. Intelligence was average. Judgment was good. Abstracting ability was adequate. Insight was limited. The diagnosis was dysthymic disorder. A muscle biopsy of the left deltoid and vastus lateralis in October 1989 resulted in a diagnosis of focal endomysial lymphocytes, rare degenerating myofiber and chronic, active neurogenic atrophy. It was noted that the amount of inflammation was minimal and that the absence of regeneration myofibers precluded the diagnosis of polymyositis. Additionally there was no evidence for inclusion body myositis or vasculitis. On VA orthopedic examination in March 1990 the veteran walked with a very marked limp with poor pushoff, short weight bearing and a borderline Trendelenburg let down on the left. She could not walk on the heel or toe on the left side. She stood with a shifting list, mostly to the left and flexed to 40 degrees, extended to 20 degrees, bent to 30 degrees and rotated to 20 degrees with variable shift of muscle tone and 1" chest expansion. There were areas of hyperesthesia and paresthesia throughout the left leg. There were some pigmentation changes on the left lower extremity, especially on the inner thigh. Range of motion of the left knee was from 5 degrees hyperextension to 130 degrees flexion compared to 5 degrees hyperextension and 140 degrees extension on the right. She had full range of motion of the hip, but with pain at all limits of motion on the left. Gluteus medius function on the left was poor, barely holding the extremity against gravity. Abduction of the left shoulder was limited by 30 degrees and rotation by 20 degrees as compared to the right. Crepitation with rotation was more apparent in the right shoulder. She had full range of motion of the cervical spine. On neurologic examination it was noted that the veteran had profound atrophy of the left leg with instability of the low back and low back pain, pain and discomfort in many joints of the upper and lower extremities and some incipient weakness of the left upper extremity with a depressive reaction. Examination revealed that the veteran had marked atrophy of the left lower extremity with decreased muscle tone especially in the left lower extremity and to some extent in the left upper extremity. There was mild weakness of the left upper extremity and somewhat greater weakness in the left lower extremity in all muscle groups. There was pain on motion of the other extremities making the veteran unable to completely cooperate with strength tests. Deep tendon reflexes were hypoactive, but equal and preserved throughout at 1+. There were no pathologic reflexes or clonus. Sensory examination and coordination were normal. Gait was slowed and somewhat hesitant with guarding of the back and limping of the left leg. The impression was neuromuscular disorder, not precisely classifiable, moderately severe and apparently progressive. The examiner opined that adaptive devices in the home would be of help. On psychiatric examination the veteran complained of feeling depressed because of her physical problem, difficulty sleeping because of pain and nervousness, wanting to be alone and feeling worthless. She reported problems with memory and concentration. She described past auditory and visual hallucinations. Examination revealed that eye contact was sporadic. She exhibited mild psychomotor retardation. Speech was mildly slowed. Mood was depressed and somewhat angry. Affect was consistent with mood. She denied current hallucinations. She expressed what appeared to be paranoid delusions concerning her neurologist. She was oriented to person, place, situation and time. Remote, recent and immediate recall were good. Intelligence was average. Judgment was questionable. Abstracting ability was adequate. Insight was very limited. The diagnosis was major depression with psychotic features. In a letter dated in June 1990, Dr. Subramony reported that the diagnosis of the veteran’s illness was focal inflammatory myopathy, a variant of polymyositis. The veteran was hospitalized at a VA facility in October and November 1990 for further evaluation of suspected inflammatory myopathy and possible neuropathic processes. Examination revealed that range of motion of the neck was limited in all directions. There was marked atrophy of the left lower extremity. Motor examination was compromised by pain in the left shoulder. Muscle strength was 5- to 5 on the right side, 3-4/5 in the left upper extremity and 3/5in the left lower extremity with slightly more proximal than distal involvement. Deep tendon reflexes were normal in both upper extremities, brisk at the knees and grade 1/4 at both ankles. Sensory examination revealed a mildly decreased vibratory sensation in the distal left lower extremity. Proprioception was intact on the right, but slightly decreased in the left lower extremity. Light touch and pinprick were decreased in the left side, more in the leg than in the arm. A small diminution of sensation in the left face was also noted. EMG and nerve conduction studies revealed a mild distal sensory polyneuropathy in both lower extremities. The veteran and her mother testified at a hearing before a hearing officer at the RO in February 1991. She stated that her left leg was weak and the pain was severe so that she could hardly put weight on it. She was depressed all of the time because of her condition. She related that her house did not have ramps or bathtub rails. She indicated that she was not yet in a wheelchair, but that she might be eventually. On VA orthopedic examination in April 1991 the veteran complained of her right lower extremity feeling nearly as bad as the left. Examination revealed that the lower extremity atrophy appeared more definite than in March 1990. There was a biopsy incisional scar behind the right fibula which was apparently painful. Her gait was altered. She preferred putting weight on her right forefoot rather than putting the whole foot down. Range of motion of the ankle was not impaired. Reflexes were active, although left ankle jerk was relatively depressed. The impression was neuromyopathology, especially in the left lower extremity, but with widespread subjective features and increased myalgia. On neurologic examination it was reported that the veteran had marked atrophy of the left lower extremity, weakness on the left side, mainly in the leg and, to a lesser degree, in the arm, and inability to exert herself because of joint pain and occasional swelling in her distal extremities. Sensory examination showed only mild decreases distally in the lower extremities. Gait was slow and hesitant with a limp. On psychiatric examination it was noted that the veteran exhibited psychomotor retardation. Her speech was somewhat halting. Mood was depressed and affect was appropriate. There were no current hallucinations or delusions. Eye contact was poor and she was precisely oriented to person, place, situation and time. Remote, recent and immediate recall were good. It was also noted that she had experienced vague auditory and visual hallucinations as recently as several weeks earlier. The diagnosis was major depression with psychotic features. The veteran was hospitalized at a VA facility in January 1992 complaining of a burning pain in the right shoulder with some decrease in ability to move the shoulder. Examination revealed muscle atrophy of the left buttock, thigh and calf. There was weakness, particularly of the left deltoid, left quadriceps and leg flexors and left calf. There were well healed biopsy sites on the left deltoid and left lateral thigh. There was tenderness of the deltoids, trapezius, bilaterally, lumbar paraspinous, buttocks, left thigh and calf muscles. In a letter dated in March 1992, Frederick W. Miller, M.D., of the National Institutes of Health reported that the veteran complained of increased diffused stiffness, arthralgias, fatigue, increased bust size, costochondritis, lower back pain, jaw pain and general progression of her disease. Examination revealed that she had diffuse muscle tenderness and joint tenderness without true synovitis, collapsing weakness secondary to pain which made it difficult to assess her true weakness and diffuse motor atrophy of the left leg and buttocks. There was diffuse costochondritis of the chest, anteriorly, and a sensory hyperesthesia of the right chest area. She had probable carpal tunnel syndrome on the right with tenderness and a positive Phalens sign. Activities of daily living testing resulted in a score of 36 out of a total of 54 which was interpreted as slightly decreased activities. The assessment was that the veteran had an undefined neuromyopathy with a long and complex history of many laboratory tests, some of which were contradictory. On VA examination in March 1994, it was noted that the veteran had a consistent right short weight-bearing limp. She could not walk on her toes because of pain and could not do heel walking on the right. The right lower extremity was about the same length as, but was ¾" larger at the calf than, the left. There was a healed incisional scar behind the fibular malleolus which was tender. Knee jerk was 2+ and ankle jerk was 1+. She had poor strength, especially in the extensor of the great toe. Stretch test was said to be very painful all the way up to the hip and back. Standing examination was not possible. Any attempt to demonstrate flexion or other motions of the back was too painful. She had to hold on and apparently could not carry out a smooth demonstration. Sitting, she had tenderness over the low back especially over the sacrum. Flexion was to 60 degrees, extension to 5 degrees, bending to 15 degrees and rotation to 10 degrees in a sitting position. Chest expansion was ¾". On the right wrist there was a healed 4" incisional scar across the carpal tunnel and around the base of the thumb. The scar seemed to be tender, and there was tenderness over the ulnar nerve at the wrist. On neurological examination in April 1994, marked atrophy of the left lower extremity was noted. Muscle tone was normal to decreased throughout. Muscle strength was 4/5 in the left lower extremity and only partially testable in the right lower extremity because of pain on movement. Muscle strength was 4/5 in both upper extremities. Straight leg raising was positive at 70 to 80 degrees on the right, but not on the left. Gait was uneven. There was decreased pain and temperature perception in the C7 and possibly the C8 dermatomes on the right. There was no sensory loss in the distribution of the median nerve. There was decreased pain and temperature perception in the L5 dermatome on the right. Deep tendon reflexes were present and equal at 1-2+ in both upper extremities and the right lower extremity, but decreased in the left lower extremity, especially in the knee. The impression was radiculopathies in the cervical and lumbosacral region, residuals of a carpal tunnel syndrome, and generalized neuromuscular disorder. The examiner opined that all three processes were connected. On VA neurological examination in October 1994 the veteran complained of constant and severe pain. She reported that she could barely walk because of the pain. Examination revealed that moving her extremities elicited pain to the extent that almost anything the examiner did with her or asked her to do resulted in severe discomfort. There was significant atrophy of the entire left lower extremity, unchanged since the last examination. Straight leg raising caused complaint of pain in the lower extremities, but she did not have typical straight leg raising abnormalities on either side. Strength was difficult to assess, but was at least 4/5 in all muscle groups, including the weakened muscle groups of her left lower extremity. Her gait was slow and hesitant and she complained of discomfort in her back when she tried to walk. She would not stand on her heels or toes, complaining of too much pain. Sensory examination showed a minor decrease in pain and temperature perception over the left lower extremity. Deep tendon reflexes were present and equal at 1+ including both ankle jerks and there were no pathologic reflexes or clonus. The impression was neurologically unchanged. The examiner noted that the veteran could walk, but only short distances because of discomfort. On psychiatric examination in October 1994, the veteran complained of being nervous and afraid a lot. She stated that she felt depressed, could not sleep because of pain, wanted to stay by herself and felt worthless. She had trouble concentrating and had auditory hallucinations as recently as March 1994. Examination revealed that mood and affect were depressed. She was precisely oriented to person, place, situation and time. Remote, recent and immediate recall were good. Intelligence was average; judgment was good. Abstracting ability was good; insight was fair. The diagnosis was major depression, recurrent, severe, with psychotic features. On muscle examination in November 1994, it was noted that the veteran could walk without assistance with a limping gait. She could stand and get on and off the examining table without assistance. She had difficulty performing range of motion of the hips because of lower back pain and she could not lay flat on the table for a prolonged period of time. There was atrophy in the left lower leg with 4/5 weakness of the quads and gastrocnemius on the left and atrophy of the calves and thigh muscles. The left foot was tender on the dorsal aspect and at the great toe and there was bunion formation at the left great toe with callous formation underneath. She could not dorsiflex or plantar flex the left foot. Passive motion of the left ankle was normal. There was tenderness on the medial aspect of the left knee. Range of motion from 0 degrees to 110 degrees. Range of motion of the left hip could not be determined. Examination of the right lower extremity revealed that she could plantar flex and dorsiflex the right foot and could resist. The toes could bend and flex. Range of motion of the right ankle was normal. There was no calf or quadriceps atrophy. The right knee was tender, but there was no swelling or instability and range of motion was normal. Range of motion of the right hip could not be determined because of severe pain. Examination of the right upper extremity revealed that she had pincher grasp only. Range of motion of the wrist was from 20 degrees flexion to 40 degrees extension. There was no ulnar deviation. There was minimal swelling of the second and third metacarpal phalangeal joints. The elbow was tender with normal range of motion. The shoulder was very tender with thickened synovium. Range of motion was limited due to pain and swelling. Forward flexion was to the mid point only. Adduction could “touch posing shoulder” with pain. Abduction was limited by 10 degrees. Internal and external rotation were markedly limited, to about 10 degrees each, by synovial thickening, swelling and pain. There were positive trigger points in the posterior shoulder girdles bilaterally. Examination of the left upper extremity revealed that the hand could close completely and grip was adequate. She could grasp a pencil. The metacarpal phalangeal joints were slightly swollen, but there were no definite deformities. Range of motion of the wrist was from 20 degrees flexion to 50 degrees extension. There was slight swelling in the wrist. The elbow was tender without swelling. Range of motion was normal. The shoulder was tender anteriorly. Forward flexion was past the midline and was normal. Adduction and abduction caused pain and were limited to 15 degrees. The deltoid was weak. There was no discernable atrophy in the biceps or triceps in either upper extremity. Examination of the spine revealed diffuse tenderness in the lumbosacral spine muscle area. Flexion was to 15 degrees, extension to 5 degrees, lateral bending to 10 degrees and rotation to 10 degrees bilaterally. Straight leg raising caused back pain with some radiation down the right leg. Gait was antalgic on the left. Push-off was assisted by her arms when getting up from a sitting position. The proximal muscles in all extremities were tender to palpation. A report of an examination by H. Louis Harkey, III, M.D., dated in June 1995 reveals that the left leg was much smaller than the right. She could walk on her heels and toes without evidence of weakness. A CT scan showed a lateral disc herniation in the foramen on the right at L5/S1. In September 1996 Dr. Harkey reported that the veteran complained of increased pain. Examination revealed that she had exquisite tenderness to light palpation in the lumbar spine. She was unable to bend in any direction without pain. She was able to walk on her toes, but not on her heels. VA out-patient clinic records dated from September 1993 to January 1996 reveal that the veteran continued to receive treatment for her service connected disabilities. In June 1995 it was reported that she was not shutting herself off from other people as much as she had in the past. In August 1995 she reported that Prozac helped her. In November 1995 she stated that she had no depressed moods as long as she took Prozac. Clinical records from Chris Benson, M.D. dated from March 1992 to March 1997 reveal that the veteran saw Dr. Benson regularly over that period for treatment of her service connected disabilities. The earlier reports show similar findings to those reported by other examiners. In December 1996 it was reported that the veteran was still ambulatory without a cane or other assistive device. In March 1997 it was noted that she had reflexes in her legs and there was no foot drop. Additional medical records received from Dr. Benson dated from June to October 1997, from Dr. Subramony dated in April and May 1997, and from a VA facility dated from February to August 1997 show that the veteran’ s disabilities continued essentially unchanged. Lower Extremities The appellant’s neuro-muscular disorder is not listed in the rating schedule. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1998). Analogous rating is possible under 38 C.F.R. § 4.124a, Code 8023 (1998) which provides for rating progressive muscular atrophy. A minimum rating of 30 percent is provided. Otherwise, ratings are by comparison with the mild, moderate, severe, or complete paralysis of the peripheral nerves affected. An 80 percent rating is provided for complete paralysis of the sciatic nerve in which the foot dangles and drops, no active movement is possible of muscles below the knee and flexion of the knee is weakened or lost. A 60 percent rating is provided where there is severe incomplete paralysis with marked muscular atrophy. A 40 percent rating is provided where symptoms are moderately severe, a 20 percent rating is provided where symptoms are moderate and a 10 percent rating is provided where symptoms are mild. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.124a Code 8620 (1998). The veteran has significant atrophy of the left lower extremity with some weakness of the muscles involve. She also has tenderness of the muscles and pain on most movements of the left lower extremity. On walking she exhibits a significant limp on the left side. On one examination in November 1994 it was reported that she could not flex or dorsiflex her left foot; but she had movement in that joint on other examinations, and in March 1997 Dr. Benson specifically reported that there was no foot drop. The record also shows that the veteran is able to walk unaided. In view of the remaining function of the veteran’s left lower extremity, the Board concludes that complete paralysis of the left sciatic nerve is not demonstrated. The currently assigned rating of 60 percent contemplates marked muscular atrophy. It is not shown that that rating inadequately compensates the veteran for the disability of the left lower extremity demonstrated by the medical evidence of record. With regard to the right lower extremity, the medical evidence shows that the veteran retains fairly normal function. Strength and range of motion in the foot, ankle and knee were reported to be normal. There was no muscle atrophy in the right lower extremity. There was tenderness in the knee and pain on motion of the hip. In the absence of muscle atrophy, weakness or loss of motion there is no basis for finding that there is more than mild symptomatology involving the right lower extremity in this case. Upper Extremities An 80 percent rating is provided for complete paralysis of all radicular groups of the minor extremity. A 60 percent rating is provided where there is severe symptomatology, a 30 percent rating is provided where there is moderate symptomatology and a 20 percent rating is provided where there is mild symptomatology. 38 C.F.R. § 4.124a Code 8613 (1998). The upper radicular group affects shoulder and elbow movement; the middle radicular group affects adduction, abduction and rotation of the arm, flexion of the elbow and extension of the wrist; and the lower radicular group affects the intrinsic muscles of the hand and the flexors of the wrist and fingers. Codes 8610, 8611, and 8612. The veteran is right handed, so the ratings for the minor extremity apply in rating the disability of the her left upper extremity. The record shows that she has good grip strength and movement of the wrist and elbow were not significantly reduced. There was tenderness of the shoulder and elbow and motion of the shoulder was somewhat limited. While there was no atrophy in the left upper extremity, the left deltoid was weakened. It is the decision of the Board that the veteran’s left upper extremity symptoms, particularly muscle weakness and limitation of motion of the shoulder, amount to moderate disability and a 30 percent rating is assigned. With regard to the right (major) upper extremity, a 90 percent rating is provided for complete paralysis of all radicular groups of the extremity. A 70 percent rating is provided where there is severe symptomatology, a 40 percent rating is provided where there is moderate symptomatology and a 20 percent rating is provided where there is mild symptomatology. 38 C.F.R. § 4.124a Code 8613 (1998). Additionally, the veteran has carpal tunnel syndrome on the right. Carpal tunnel syndrome involves the median nerve. The rating schedule provides a 70 percent rating for complete paralysis of the median nerve of the major extremity. A 50 percent rating is provided where there is severe symptomatology, a 30 percent rating is provided where there is moderate symptomatology and a 10 percent rating is provided where there is mild symptomatology. Code 8515. Complete paralysis of the median nerve results in the hand being inclined to the ulnar side, the index and middle fingers being more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb being in the plane of the hand, pronation being incomplete and defective, absence of flexion of the index finger and feeble flexion of the middle finger, inability to make a fist, the index and middle fingers remain extended, inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at right angles to the palm, weakened flexion of the wrist and pain with trophic disturbances. The record shows that the veteran has only pincher grasp in the right hand. There is limitation of motion of the right wrist and tenderness of the elbow and shoulder with synovial thickening in the shoulder. Motion of the shoulder is also limited. The RO assigned a 40 percent rating under Code 8613 which contemplates incomplete paralysis of all radicular groups with moderate symptomatology. That rating accounts for the demonstrated disability involving the veteran’s shoulder and elbow, but does not fully recognize the additional disability involving the hand and wrist. Accordingly, the Board finds that a separate 30 percent rating for incomplete paralysis of the median nerve under Code 8515 based on moderate symptomatology resulting from the carpal tunnel syndrome is warranted. At the same time, the Board finds that the remaining function of the right upper extremity including pincher grasp in the hand, full range of motion of the elbow and the absence of any reported atrophy or muscle weakness precludes a finding that the disability of either the radicular groups or the median nerve is severe. Psychiatric Under the rating schedule provisions in effect prior to November 7, 1996 a 50 percent rating was provided for major depression with psychotic features where there was considerable impairment of social and industrial adaptability. A 100 percent rating was provided where there were active psychotic manifestations of such extent, severity, depth, persistence or bizarreness as to produce total social and in adaptability. A 70 percent rating required lesser symptomatology such as to produce severe impairment of social and industrial adaptability. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.132 Code 9207 (1996). Under the rating schedule provisions which became effective on November 7, 1996, a 50 percent rating is assigned for a major depressive disorder where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood due to such symptoms as: suicidal ideation; obsession rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned where there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. § 4.130 Code 9434 (1998). The record shows that the veteran’s psychiatric symptoms include depression, insomnia, feelings of worthlessness, difficulty concentrating and occasional hallucinations. On the most recent examination, her mood and affect were depressed. She was precisely oriented to person, place, situation and time. Remote, recent and immediate recall were good. Intelligence was average and judgment was good. Abstracting ability was good and insight was fair. Considering the disability picture presented by the medical evidence accumulated in this case over the last few years in relation the criteria in effect prior to November 7, 1996, the Board concludes that the veteran’s symptoms approximate the considerable level of impairment for which a 50 percent rating is assignable and that is the rating currently in effect. While the veteran’s psychiatric disorder would clearly interfere to some degree with her ability to work, the evidence does not demonstrate the severe impairment contemplated in assigning a 70 percent rating. Since the evidence shows that the veteran retains memory and the ability to think abstractly and exercise judgment, her industrial impairment cannot be said to be severe. Considering the veteran’s symptoms under the new rating schedule criteria, the Board concludes that the veteran’s impaired concentration, depressed mood and affect and occasional hallucinations approximate the criteria set out for a 50 percent rating. However, she does not demonstrate the more extensive and severe symptoms described schedular criteria for a 70 percent rating. Specially Adapted Housing Financial assistance in acquiring specially adapted housing, is provided for a veteran with service after April 20, 1898, who has a permanent and total service-connected disability due to: (1) The loss, or loss of use, of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; or (3) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 38 U.S.C.A. § 2101(a) (West 1991 & Supp. 1998); 38 C.F.R. § 3.809 (1998). Financial assistance in acquiring special home adaptations is available to a veteran who served after April 20, 1898, and who does not qualify for benefits under 38 C.F.R. § 3.809 where such veteran is entitled to compensation for permanent and total disability which (1) is due to blindness in both eyes with 5/200 visual acuity or less, or (2) includes the anatomical loss or loss of use of both hands. 38 U.S.C.A. § 2101(b) (West 1991 & Supp. 1998); 38 C.F.R. § 3.809a (1998). “Preclude locomotion’’ is defined as the necessity for regular and constant use of a wheelchair, braces, crutches or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(d) (1998). In order to qualify for financial assistance in acquiring specially adapted housing or in acquiring special home adaptations, the above cited law and regulations require that a veteran have disabilities meeting specific criteria. In this case the veteran is not shown to have any significant visual disability, nor is she shown to have disability resulting in anatomical loss or loss of use of both hands. While she has a rather severe impairment of the left lower extremity resulting from service connected disability, it was reported on examination in November 1994 that she could walk without assistance. At a hearing in 1991 the appellant had reported that she was not in a wheel chair, but that she might be someday. It is, therefore, evident that the appellant has not suffered loss or loss of use of both lower extremities so as to preclude locomotion, nor has she suffered loss or loss of use of one lower extremity. In the absence of evidence establishing that she meets any of the specific criteria set forth above, there is no basis in the law for granting financial assistance in acquiring specially adapted housing or in acquiring special home adaptations in this case. The Board recognizes that the veteran’s service connected disability has been progressing in severity. Medical evidence of further progression consistent with the criteria outlined above may be a basis for reopening her claim. ORDER Increased ratings for focal inflammatory myopathy of the left lower extremity and right lower extremity and for major depression with psychotic features are denied. Entitlement to financial assistance in acquiring specially adapted housing or in acquiring special home adaptations is denied. A 30 percent rating for focal inflammatory myopathy of the left upper extremity and a separate 30 percent rating under Code 8515 for focal inflammatory myopathy of the right upper extremity with carpal tunnel syndrome are granted subject to the regulations governing payment of monetary awards. GEORGE R. SENYK Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -