Citation Nr: 0505717 Decision Date: 03/02/05 Archive Date: 03/15/05 DOCKET NO. 02-13 029A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a disorder as a result of asbestos exposure. 3. Entitlement to service connection for a psychiatric disorder to include post-traumatic stress disorder. 4. Entitlement to a higher rating for service-connected chronic low back strain, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Tanya A. Smith, Associate Counsel INTRODUCTION The veteran had active service from July 1973 to July 1976 and September 1986 to September 1996, with unverified service in the United States Army Reserves from July 1976 to September 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2000 and July 2002 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The RO certified all of the issues cited above to the Board. Technically, the veteran's Substantive Appeal (VA Form 9), filed in September 2002, was only for his claim of entitlement to service connection for post-traumatic stress disorder. The Board will liberally construe the September 2002 Substantive Appeal to include the veteran's claim for service connection of a mental disorder in general as reflected in the July 2002 Statement of the Case (SOC). The Board will also accept a statement and attached medical records from the veteran received by the RO in January 2003, as a Substantive Appeal on the remaining issues of entitlement to service connection for a left knee disorder and an asbestos-related disorder and entitlement to an increased rating for service-connected chronic low back strain, as reflected in the July 2002 SOC. The submitted medical records referenced treatment the veteran received and complaints the veteran made concerning his left knee, bronchitis, and low back. Also, the statement and medical records were received by the RO within one year from the date of mailing of the notification of the July 2002 rating decision (Hearing Officer's Decision), wherein the RO readjudicated the low back claim as well as reopened and readjudicated previously disallowed knee, mental, and asbestos-related disorder claims in light of the Veterans Claims Assistance Act of 2000. 38 C.F.R. § 20.302(b) (2003). (The July 2002 rating decision is a continuation of the October 2000 rating determination being appealed.) The Board notes that additional evidence was associated with the claims file after the July 2002 SOC. The RO did not issue a Supplemental Statement of the Case (SSOC). See 38 C.F.R. § 19.37(a) (2004) (providing that if the last SOC or SSOC was prepared before the receipt of additional evidence, a SSOC will be furnished to the veteran unless the additional evidence is duplicative or not relevant to the issue on appeal). Nevertheless, the RO readjudicated the PTSD and low back claims with consideration of all the evidence of record as reflected in the January 2004 rating decision. With regard to the mental and asbestos claims, the additional evidence submitted after the July 2002 SOC was duplicative or not relevant to the issue. In December 2004, the Board received additional evidence from the RO that consisted of service medical records, private medical records, and DD Form 214s, that were duplicative or cumulative of evidence previously considered by the RO in connection with the veteran's claims or were not relevant to the issues on appeal. Accordingly, the Board finds no basis for remanding the issues on appeal to the RO for its initial consideration of the additional evidence in connection with the veteran's claims. See Board of Veterans' Appeals: Obtaining Evidence and Curing Procedural Defects, 69 Fed. Reg. 53,807 (September 3, 2004) (to be codified at 38 C.F.R. §§ 19.9, 20.1304(c)). In a June 2004 statement, the veteran indicated that he wanted to withdraw the issue of entitlement to an effective date earlier than June 12, 2000, for the grant of an increased rating of 20 percent for service-connected chronic low back strain. At the July 2004 travel board hearing, the veteran submitted a signed statement that indicated that he wanted to withdraw the issue of entitlement to service connection for a right knee disorder. Accordingly, these issues are not before the Board. The issue of entitlement to service connection for a left knee disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The veteran has been notified of the evidence necessary to substantiate his claims, and all relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. The evidence of record shows that the veteran was likely exposed to asbestos during service. 3. The competent medical evidence of record shows no radiographic evidence of parenchymal lung disease. 4. The competent medical evidence of record shows that the veteran is not currently diagnosed with an asbestos-related disorder. 5. There is credible supporting evidence of record that the veteran's claimed stressor of physical assault occurred in- service. 6. The competent medical evidence of record shows that the veteran does not currently meet the criteria for post- traumatic stress disorder. 7. The competent medical evidence of record shows that the veteran's currently diagnosed anxiety disorder or dysthmia did not have its onset during a period of service; there is no competent medical evidence of record that otherwise establishes that an anxiety disorder or dysthmia is related to service. 8. Throughout the rating period on appeal, the veteran's low back disability is manifested by subjective complaints of pain with radiculopathy to the right groin area/lower extremity and fatigue on prolonged use, productive of no more than moderate limitation of motion with functional loss due to pain and fatigue, with no more than mild neurological deficit. CONCLUSIONS OF LAW 1. A chronic disorder as a result of asbestos exposure was not incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2004). 2. Post-traumatic stress disorder was not incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131, 1154(b), 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304(d), (f) (2004). 3. An anxiety disorder or dysthymia was not incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2003). 4. The schedular criteria for a rating in excess of 20 percent for service-connected chronic low back strain, prior to September 23, 2002, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.27, 4.40-4.46, 4.59 (2004); 38 C.F.R. § 4.71a, Diagnostic Codes 5292, 5295 (2003); 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2002). 5. The schedular criteria for a separate 20 percent rating, but no higher, for orthopedic manifestations of the service- connected chronic low back strain, from September 23, 2002 to September 25, 2003, have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.27, 4.40-4.46, 4.59 (2004); 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2003). 6. The schedular criteria for a separate 10 percent rating, but no higher, for neurologic manifestations of the service- connected chronic low back strain, from September 23, 2002 to September 25, 2003, have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.27, 4.40-4.46, 4.59, 4.124a, Diagnostic Code 8520 (2004). 7. The schedular criteria for a separate 20 percent rating, but no higher, under the General Rating Formula for Diseases and Injuries of the Spine, for the service-connected chronic low back strain, from September 26, 2003, have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.27, 4.40-4.46, 4.59, 4.71a, Diagnostic Code 5243 (2004). 8. The schedular criteria for a separate 10 percent rating, but no higher, for neurologic abnormalities of the service- connected chronic low back strain, from September 26, 2003, have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.27, 4.40-4.46, 4.59, 4.71a, Diagnostic Code 8520 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000, Pub. L. No. 106- 475, 114 Stat. 2096 (2000) (VCAA) redefines the obligations of VA with respect to the duty to assist and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2004). VA is required to provide the claimant with notice of what information or evidence is to be provided by the Secretary and what information or evidence is to be provided by the claimant with respect to the information and evidence necessary to substantiate the claim for VA benefits. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Board finds that VA's enhanced duty to notify under the VCAA has been met. In this regard, the Board notes that the RO provided the veteran with a copy of the October 2000 rating decision, July 2002 rating decision, July 2002 SOC, and January 2004 rating decision, which together provided the veteran with notice as to the evidence needed to substantiate his claims, the reasons for the rating assigned, and the reasons for the denials. The July 2002 rating decision, July 2002 SOC, and January 2004 rating decision provided the veteran with notice of laws and regulations pertinent to his claims, including the law and implementing regulations of the VCAA. The Board notes that the schedule for rating spine disabilities was amended in August 2003, effective September 26, 2003. Amendment to Part 4, Schedule for Rating Disabilities, 68 Fed. Reg. 51454-51458 (August 27, 2003) (codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5235, 5236, 5237, 5238, 5239, 5240, 5241, 5242, 5243 (2004)). Prior to that, the rating criteria for evaluating intervertebral disc syndrome were changed, effective September 23, 2002. Amendment to Part 4, Schedule for Rating Disabilities, 67 Fed. Reg. 54345-54349 (August 22, 2002) (former 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003)). The new rating criteria for intervertebral disc syndrome were subsumed in the aforementioned amended rating schedule for spine disabilities. When the regulations concerning entitlement to a higher rating are changed during the course of an appeal, the veteran is entitled to resolution of his or her claim under the criteria that are more to his or her advantage. VAOPGCPREC 3-00. The January 2004 rating decision shows that the RO considered the veteran's low back disability under the old and new schedule for rating spine disabilities. Lastly, the Board notes that in correspondence dated in March 2001, April 2003, and August 2003, the RO advised the veteran of VA's duties under the VCAA and the delegation of responsibility between VA and the veteran in procuring the evidence relevant to his claims, including which portion of the information and evidence was to be provided by the veteran and which portion VA would attempt to obtain on behalf of the veteran. Quartuccio, 16 Vet. App. at 187. In particular, the March 2001 VCAA notice specifically asked the veteran to provide VA with any evidence regarding treatment he had received for his back condition since the RO hearing. The Board notes that where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Thus, the requested current evidence was the evidence necessary to substantiate the veteran's claim that his low back disability had increased in severity. The VCAA notice specifically advised the veteran that VA would assist him if he needed any assistance in obtaining any evidence he believed was pertinent to his claim. During the course of this appeal, the United States Court of Appeals for Veterans Claims (Court) handed down Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). In Pelegrini II, the Court reaffirmed that the enhanced duty to notify provisions under the VCAA should be met prior to an initial unfavorable agency of original jurisdiction (AOJ) decision on the claim. In the instant appeal, the Board notes that the initial unfavorable rating decision was rendered prior to the enactment of the VCAA; therefore, it was impossible for VA to provide notice pursuant to the enhanced duty to notify provisions of the VCAA prior to the initial AOJ decision. Nevertheless, the case was reconsidered again in July 2002 and January 2004 and the rating decisions were provided to the veteran. The veteran has been provided with every opportunity to submit evidence and argument in support of his claims and to respond to VA notices. The Board also acknowledges that the VCAA notices contained no specific request for the veteran to provide any evidence in the veteran's possession that pertained to the claims, or something to the effect that the veteran give VA everything he had that pertained to his claims. 38 C.F.R. § 3.159 (b)(1) (2004). Nevertheless, the RO asked the veteran for all the information and evidence necessary to substantiate the veteran's claims. A generalized request for any other evidence pertaining to the claims would have been superfluous and unlikely to lead to the submission of additional pertinent evidence. Therefore, it can be concluded, based on the particular facts and circumstances of the case, the omission of the request for "any evidence in the claimant's possession that pertains to the claim" in the notices appears not to have harmed the veteran, and it would be legally proper to render a decision in the case without further notice under the regulation. The Board also concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the veteran that any additional information or evidence is needed. Quartuccio, 16 Vet. App. at 187. In regard to VA's duty to assist, the Board notes that the RO afforded the veteran VA examinations in April 2001 and February 2002, including an evaluation for asbestos exposure. The RO also obtained VA treatment records. Service medical records and reserve service medical records were previously associated with the claims file; these records contained evidence that the veteran was likely exposed to asbestos during service. The RO afforded the veteran a local hearing before a Hearing Officer of the RO in February 2001 and scheduled the veteran for a travel board hearing, which was held in July 2004. In a May 2002 request to VA for medical records, the Social Security Administration (SSA) indicated that the veteran had a claim for disability benefits before its Office of Hearings and Appeals. At the April 2001 VA mental examination, the veteran reported that he filed a claim for Social Security disability benefits for his back problems. VA treatment records dated in June and July 2003, however, noted that the veteran reported that he was declined Social Security disability benefits. As the veteran is reportedly not currently in receipt of Social Security disability benefits, the Board finds that the evidence SSA considered in its determination is not relevant to the veteran's low back claim. Therefore, the Board is under no duty to obtain these records. The veteran has not made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the veteran in developing the facts pertinent to his claim. The Board also finds that development pursuant to VA Adjudication Procedure Manual, M21-1 with regard to the veteran's asbestos claims has been completed. Accordingly, the Board will proceed with appellate review. II. Service connection for a Disorder Secondary to Asbestos Exposure The Board observes that there is no specific statutory guidance with regard to asbestos-related claims, nor has the Secretary promulgated any regulations. VA, however, has issued a circular on asbestos-related diseases which provides some guidelines for considering compensation claims based on exposure to asbestos. Department of Veterans Benefits, Veterans' Administration, DVB Circular 21-88-8, Asbestos- Related Diseases (May 11, 1988) (DVB Circular). The information and instructions from the DVB Circular are incorporated in the VA Adjudication Procedure Manual, M21-1 (M21-1), Part VI, 7.21. The provisions of M21-1, Part VI, par. 7.21(a), (b), & (c) are not substantive in nature, but relevant factors discussed by them must be considered by the Board in all decisions in order to fulfill the Board's obligation under 38 U.S.C.A. § 7104(d)(1) to provide an adequate statement of the reasons and bases for a decision. See VAOPGCPREC 4-00; Ennis v. Brown, 4 Vet. App. 438, vacated at 4 Vet. App. 523, new decision issued at 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). The first three sentences of M21-1, Part VI, par. 7.21(d)(1) are substantive in nature and must have been followed by the agency of original jurisdiction or the appeal must be remanded for this development. See VAOPGCPREC 4-00. Additionally, while not discussed in VAOPGCPREC 4-00, it is likely that factors enumerated at M21- 1, Part III, par. 5.13(b) should be considered by the Board. The guidelines further provide that the latent period varies from 10-45 years or more between first exposure and development of disease. M21-1, part VI, para. 7.21(b)(1) and (2). It is noted that an asbestos-related disease can develop from brief exposure to asbestos or as a bystander. The guidelines identify the nature of some asbestos-related diseases. The most common disease is interstitial pulmonary fibrosis (asbestosis). Asbestos fibers may also produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, lung cancer, and cancers of the gastrointestinal tract. See M21-1, part VI, para. 7.21(a)(1). Finally, the guidelines provide that the clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. The veteran's service medical records include a July 1989 letter from the Department of the Army to the veteran on the subject of medical attention for possible exposure to asbestos. The service official acknowledged that the veteran had been assigned to a building that was recently condemned. The service official directed the veteran to set up an appointment for a chest x-ray and baseline pulmonary function test at his earliest convenience. Based on the July 1989 letter, the Board concedes that the veteran was likely exposed to asbestos during service. The medical evidence of record, however, shows that the veteran is not currently diagnosed with an asbestos-related disorder. The service medical records include a March 1995 record that noted a history of asbestos exposure, but the chest x-ray was normal. A February 1996 consultation sheet showed that the veteran was referred for an evaluation of remote asbestos exposure. The consultant reported that there was no evidence of asbestosis. An April 1996 record indicated that a chest x-ray was normal, and there was no evidence of pleural thickening or calcifications. The examiner noted an assessment of history of asbestos exposure with no evidence of asbestosis by chest x-ray or exam. Post-service medical evidence includes March 1997 VA pulmonary function tests (PFTs) that revealed a mild restriction. A July 1997 VA chest x-ray, however, revealed clear lungs, and the mediastinal and hilar structures and the bony thorax were unremarkable. The interpreter noted that the chest x-ray was normal. An April 2001 VA record noted that views of the chest were similarly unremarkable and unchanged when compared to the prior exam in July 1997. The April 2001 VA asbestos examination report showed that the examiner noted that the chest x-ray was unremarkable. The examiner indicated that there was no evidence of any pleural or diaphragmatic calcification. Lastly, a December 2002 VA chest x-ray noted impressions of suboptimal inspirated study with some crowding of the bronchovascular markings, but no definite acute parenchymal disease was noted. Thus, the service medical records and post-service medical records show no radiographic evidence of parenchymal lung disease. Also, the medical evidence shows that the veteran is not currently diagnosed with an asbestos-related disorder as a result of asbestos exposure. Therefore, service connection for an asbestos-related disorder as a result of asbestos exposure is not warranted on the basis of the current evidence. The Board is cognizant of testimony the veteran provided at the July 2004 travel board hearing in which he indicated that he had been prescribed inhalers by VA for episodes of wheezing. The medical evidence shows that the veteran has been diagnosed with bronchitis; however, this disorder has not been medically attributed to asbestos exposure. As noted above, the Board does not doubt that the veteran was, indeed, exposed to asbestos during service, but without medical evidence of a disorder due to that exposure, the claim must be denied. Exposure to asbestos, in and of itself, is not considered a disability for VA purposes. As the preponderance of the evidence is against the claim, the "benefit of the doubt" doctrine is not applicable, and the claim must be denied. 38 U.S.C.A. 5107(b) (West 2002); 38 C.F.R. § 3.102 (2003); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Service Connection for Post-Traumatic Stress Disorder/Mental Disorder A. Post-Traumatic Stress Disorder (PTSD) The veteran contends that he has post-traumatic stress disorder (PTSD) as the result of a physical assault that reportedly occurred during service. VA regulation 38 C.F.R. § 3.304(f) (2004) sets forth the three elements required to establish service connection for PTSD. For service connection to be awarded for PTSD, the record must show: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) (2004); (2) combat status or credible supporting evidence that the claimed in- service stressor actually occurred; and (3) medical evidence of a causal nexus between diagnosed PTSD and the claimed in- service stressor. With regard to the second criterion required to establish service connection for PTSD, the Board notes that the veteran's claimed stressor is not related to combat. As such, the record must contain service records or other corroborative evidence that substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressor. West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The veteran's service medical records include a statement from service member E.L.N., who reported that in April 1976, he witnessed an altercation between the veteran and another service member. E.L.N. reported that during the course of the altercation, two other service members got involved in the situation by kicking the veteran in the back and hitting the veteran around the head and shoulders. The Board finds that this in-service April 1976 statement constitutes credible supporting evidence that the claimed stressor occurred. With regard to the first criterion required to establish service connection for PTSD, there is favorable and unfavorable evidence that the veteran currently suffers from PTSD. VA treatment records show that in December 2000, Licensed Clinical Social Worker (LCSW), R.W., noted that the emotional content the veteran reported and his psychiatric symptoms seemed to indicate possible PTSD symptoms. A January 2001 record showed that Certified Physician's Assistant (PA-C), D.S., noted that the veteran had PTSD, non-combat but military related. Records dated in January 2001, June 2001, and October 2001, showed that PA-C, B.S.M., noted an assessment of PTSD. Records dated in December 2002, March 2003, and June 2003, showed that Dr. D.N. noted an impression of PTSD, relative to a non-combat physical assault, and dysthymia. The March 1997 VA examination report shows that the claims file was not made available for the examiner. Dr. K.S.R. noted that the veteran reported on the claimed in-service stressor. Dr. K.S.R. diagnosed the veteran with dysthymia. The April 2001 VA examination report shows that the claims file was not made available to the examiner. Dr. T.E.V. noted that the veteran reported on the claimed in-service stressor. Dr. T.E.V. only diagnosed the veteran with "PTSD symptoms" on Axis I, and no diagnosis on Axis II. Lastly, the February 2002 VA examination report shows that the claims file was made available to and reviewed by Dr. S.S. The veteran reported on the claimed in-service stressor. Dr. S.S. provided a diagnosis of anxiety disorder not otherwise specified on Axis I, and no diagnosis on Axis II. Dr. S.S. noted that the veteran was diagnosed with dysthymia in 1997 and he now complained of problems related to a physical attack by soldiers of a different race during his time in the military. Dr. S.S. maintained that the veteran currently did give a few symptoms related to PTSD but he did not meet the criteria for PTSD at this time. The Board must weigh the credibility and probative value of the above medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board finds that the medical opinions rendered by Drs. D.N., K.S.R., T.E.V., and S.S. are of higher probative value than those rendered by LCSW, R.W., and PA-Cs, D.S. and B.S.M., as the former possess a higher degree of medical expertise, training, and skills in the field of psychiatry. As among Drs. D.N., K.S.R., T.E.V., and S.S., the Board accords greater evidentiary weight to Dr. S.S.'s unfavorable medical opinion because it is based on an entire review of the records in the veteran's claims file, it is supported by a rationale, and is found to be persuasive when considered with the rest of the evidence of record. It is notable that there is a consensus among Drs. K.S.R., T.E.V., and S.S., that the veteran does not have PTSD. Drs. T.E.V. and S.S. specifically found that the veteran had some symptoms related to PTSD, but declined to find that the veteran met the full criteria of PTSD as set forth in DSM-IV [American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)]. Thus, the Board finds that the first criterion required to establish service connection for PTSD has not been met, and consequently, the third criterion has also not been met. Accordingly, service connection for PTSD is not warranted on the basis of the current evidence. B. Mental Disorder The evidence of record similarly shows that service connection for a mental disorder in general is not warranted. The medical evidence shows that the veteran is currently diagnosed with anxiety disorder and dysthymia. The service medical records that covered the veteran's first period of service showed that in December 1975, the veteran was referred for an evaluation as to whether the veteran's "personality change" was a reaction to his back pain. In January 1976, a consultant recommended that possible alcohol overuse should be ruled out and that the veteran should be referred to "MHCS" to rule out a possible psychiatric disorder. The consultant then noted "[p]ossible" diagnoses of personality pattern disturbance, paranoid type, and schizophrenic reaction, paranoid type. No subsequent pertinent treatment was noted in the records. The May 1976 separation examination report showed that no psychiatric disorder, anxiety disorder, or mood disorder was identified on examination, and no relevant symptomatic complaints were noted on the Report of Medical History. The veteran's service reserve medical records and service medical records for his second period of service, which together spanned some 20 years from July 1976 to September 1996, showed that no psychiatric disorder, anxiety disorder, or mood disorder was identified during this period; nor were any relevant symptomatic complaints noted during this period. Rather, dysthymia and anxiety disorder were first diagnosed in March 1997 and February 2002, respectively, after the veteran's discharge from his second period of service. Thus, the evidence does not show that the veteran's currently diagnosed anxiety disorder or dysthymia had its onset during a period of service. 38 C.F.R. § 3.303 (2004). There is also no competent medical evidence of record that otherwise establishes that an anxiety disorder or dysthymia was incurred in service. 38 C.F.R. § 3.303(d) (2004). Accordingly, service connection for an anxiety disorder or dysthymia is not warranted on the basis of the current evidence of record. As the preponderance of the evidence is against the PTSD and mental claims, the "benefit of the doubt" doctrine is not applicable, and the claims must be denied. 38 U.S.C.A. 5107(b) (West 2002); 38 C.F.R. § 3.102 (2004); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Increased Rating for Chronic Low Back Strain A. Procedural History and Evidence By a December 1976 rating decision, the RO granted service connection for chronic low back strain, and assigned a noncompensable evaluation under Diagnostic Code 5295, effective July 24, 1976, one day following the veteran's discharge from service. By an October 1997 rating decision, the RO awarded a compensable rating of 10 percent under Diagnostic Code 5295. The disability rating was based on service medical records that covered the veteran's second period of service, which included examination findings of "closed intervertebral disc space [...] decreasing at L4- 5," "reduction in normal lordosis of the spine," and "chronic lower back pain with probable disc involvement." In June 2000, the veteran filed the instant claim for an increased rating. By a July 2002 rating decision, the RO increased the veteran's disability rating from 10 percent to 20 percent under Diagnostic Code 5295. The RO granted the increased rating based on demonstrable muscle spasms shown on VA examination. At the February 2001 RO hearing, the veteran indicated that driving for long periods of time caused him to experience muscle spasms that radiated down his back and both legs as well as into the right side of his groin area. As the result, he had to leave his job as a trucker. He complained that his back bothered him almost 24 hours a day. He indicated that he took pain medication and muscle relaxants, and he sometimes received Cortizone shots. He reported that he had problems bending and lifting, and he could not stand or sit for prolonged periods of time. At the July 2004 travel board hearing, the veteran additionally testified that he had loss of motion or limited motion in his back. He indicated that his back disability inhibited his ability to do his job. He reported that when he was unable to work he would just quit the job. He testified that he currently worked in the evening and night from 3:30 p.m. until midnight. He denied that any doctor ever prescribed bed rest for him. He was last treated for his back six months ago. VA treatment records dated during the appeal period show that in July 2000, the veteran presented at the clinic with complaints of back pain. He reported that he had been driving a truck lately and today his back was hurting. He indicated that he was unable to go to work. The physical examination revealed tenderness over the right lumbar muscle. The straight leg raising (SLR) test was negative. There were no neurological deficits. The assessment was backache. Records dated in February 2003 and March 2003 showed that the veteran complained of low back pain. A March 2003 record noted that a magnetic resonance imaging (MRI) scan of the lumbar spine revealed degenerative spondylosis. An April 2001 VA spine examination report showed that the examiner reviewed the claims file. The veteran's noted complaints were similar to those he provided testimony on at the RO hearing and travel board hearing. In addition, the veteran complained that the pain in his back was aggravated with cold and damp weather, and with excessive bending, stooping, and standing. He indicated that he used a lumbar support if he were going to do any prolonged standing. The examiner noted that the physical examination revealed decreased range of motion of the lumbar spine. Forward flexion of the lumbar spine was to 40 degrees, extension to 5 degrees, left and right lateral flexion to 15 degrees, and left and right rotational to 15 degrees. The examiner noted that the veteran had "pain before range of motion" and it was "worse with the slightest movement." The examiner confirmed that pain limited the range of motion of the veteran's lumbar spine. Positive paralumbar spasms were noted with tenderness upon palpation. There were no postural abnormalities and there was good muscle tone and bulk. SLR tests were positive at 30 degrees bilaterally. Deep tendon reflexes were intact and symmetrical and no sensory loss was noted. The x-ray of the lumbosacral spine, per the radiologist, revealed mild to moderate degenerative changes at L4/5 and L5/S1 with disc space narrowing, Schmorl node formation, dense reactive sclerosis, and marginal spurring. The examiner diagnosed chronic lumbar strain with positive clinical and radiographic findings of moderate degenerative joint disease and degenerative disc disease at L4/5, L5/S1, and chronic muscular spasms as a residual effect. Private medical records (Neurological Institute, Fairview Park Hospital) dated from September 2002 to October 2002, showed that the veteran was treated for acute lumbosacral strain. A September 2002 report of a MRI noted an impression of discogenic degenerative changes at L4-5 and L5-S1, which were exacerbated by the narrow "AP" canal diameter. A September 2002 report noted that a physical examination of the lumbar spine revealed some taut bands over the veteran's lumbar paraspinals. There was some tenderness "in these" and some pain to percussion. Flexion was within eight inches of toe touch. Range of motion on extension and right and left lateral bend were all normal. Left lateral bend caused some low back pain. The SLR test was negative bilaterally. The x-ray revealed some facet hypertrophy and loss of disc space at L4 and L5. The impression was subacute to chronic low back pain. Dr. J.T.H. noted that while he would continue the veteran on Vioxx, unfortunately the veteran had not been responsive to this or conservative treatments. An October 2002 report by Dr. R.P.B. noted that a physical examination revealed no tenderness over the lumbar spine. The veteran was able to bend over about 70 to 80 degrees at the waist. The SLR test was negative to 90 degrees bilaterally. The MRI revealed some congenital spinal stenosis with a small canal. The MRI also revealed some degenerative changes at L4-5 and L5-S1 with some broad based bulging discs and osteophyte, resulting in some mild stenosis at that level. Dr. R.P.B. then noted that the veteran's neurologic exam was "pretty normal." Dr. R.P.B. maintained that while the veteran had some pre-existing stenosis, his symptoms seemed more like a strain. Lastly, Dr. R.P.B. noted that the examination revealed no evidence of nerve root compression in the lower back or any "cauda equina syndrome, etc." An October 2002 electrodiagnostic evaluation was noted as normal. The examiner commented that there was no electrodiagnostic evidence of lumbar radiculopathy, myopathy, or polyneuropathy. By way of history, the service medical records documented complaints of low back pain with radiation to the right groin area and right leg. The service medical records showed that a December 1991 radiographic report and a February 1992 radiologic consultation request/report noted mild degenerative disk disease of L4/5 and L5/S1, with perhaps three millimeters or so retrolisthesis of L5 on S1. There was also minimal degenerative joint disease at L4/5. VA treatment records were significant for a March 1995 record that noted that the lumbar spine x-ray revealed mild spondylosis and degenerative disk disease with slight narrowing of L5-S1 disk. B. Old Schedule for Rating Spine Disabilities- Prior to September 23, 2002 As a preliminary matter, the Board notes that the October 1997 and July 2002 rating decisions show that the grant of service connection for chronic low back strain includes degenerative changes at L4, L5, and S1, and muscle spasms. Indeed, service medical records and VA treatment records show that spondylosis, degenerative disc disease at L4/5 and L5/S1, as well as degenerative joint disease at L4/5, were all diagnosed during the veteran's service. The April 2001 VA examiner specifically attributed the muscular spasms demonstrated on VA examination as a residual of degenerative joint disease and degenerative disc disease at L4/5, L5/S1. The veteran's service-connected chronic low back strain is presently assigned a 20 percent rating under Diagnostic Code 5295 of the old schedule for rating spine disabilities. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2003). The above discussed medical evidence notes no examination findings of listing of the whole spine to the opposite side, positive Goldthwaite's sign, loss of lateral motion, or abnormal mobility on forced motion, which are criteria associated with a 40 percent rating under Diagnostic Code 5295. Id. Indeed, while the April 2001 x-ray revealed osteo-arthritic changes, disc space narrowing, and irregularity of joint space, these findings are not accompanied with loss of lateral motion. Rather, the objective evidence shows that the veteran has limitation of lateral motion, but not complete loss of lateral motion. Additionally, the medical evidence shows that the veteran's low back disability is not productive of marked limitation of forward bending (i.e., flexion) in the standing position, which is a criterion associated with a 40 percent rating under Diagnostic Code 5295. Id. Normal range of motion of the lumbar spine is not depicted in any way in the old schedule for rating spine disabilities. Cf. 38 C.F.R. § 4.71, PLATE II. The above physicians did not provide the figures for normal range of flexion motion. Thus, the Board will apply the 'range of motion' figures provided under the General Rating Formula for Diseases and Injuries of the Spine. Note (2) under the schedule, indicates that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2004). In the instant case, the April 2001 VA examiner's report that the veteran had "pain before range of motion" that was "worse with the slightest movement" suggests that the veteran has complete functional loss in his lower back due to pain. See DeLuca v. Brown, 8 Vet. App. 202, 205-06 (1995) (providing that additional functional loss due to pain should be reflected in a rating for limitation of motion). The examination findings noted in the April 2001 VA examination report, Dr. J.T.H.'s September 2002 report, and Dr. R.P.B.'s October 2002 report, however, tend to show that the veteran is capable of flexion motion between 70 to 80 degrees in between flare-ups (where no symptomatic findings were noted on the October 2002 examination) and flexion motion is limited to 40 degrees during flare-ups (where pain, muscle spasms, tenderness, and a positive SLR test were demonstrated on the April 2001 VA examination). Even with tenderness and pain noted in the lumber spine, the veteran was capable of reaching within eight inches of his toes at the September 2002 examination. Thus, the Board concludes that the veteran's low back disability is not productive of marked limitation of forward bending in the standing position even with consideration of additional functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2004); 38 C.F.R. § 4.71a, Diagnostic 5295 (2003). Accordingly, the Board finds that the veteran's service-connected chronic low back strain more nearly approximates the criteria associated with the currently assigned rating of 20 percent under Diagnostic Code 5295. The Board will consider other potentially applicable diagnostic codes under which the veteran may be entitled to a rating in excess of 20 percent. Under Diagnostic Code 5292, a 40 percent rating is assigned for severe limitation of motion of the lumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2003). As noted earlier, the physicians did not always report the normal range of motion of the lumbar spine. Thus, the Board will again apply the 'range of motion' figures provided under the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243, Note 2 (2004) (providing that normal extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees). At the April 2001 VA examination, limitation of motion was severe on extension, but moderate on flexion, lateral flexion, and rotation, all of which were accompanied by pain. At the September 2002 examination, limitation of motion on flexion was slight, if any, as the veteran was capable of reaching within eight inches of his toes. Dr. J.T.H. maintained that extension and right and left lateral bend were all normal, with pain noted only on left lateral bend. At the October 2002 examination, limitation of motion on flexion was slight with no pain noted. The foregoing medical findings tend to show that the veteran generally suffers from no loss to a slight loss of motion in his low back on account of his disability, however, with exacerbations precipitated by pain, there is overall loss of motion that is no more than moderate. With regard to the veteran's complaints of fatigue with prolonged use of his low back when bending, stooping, lifting, standing, or sitting, the Board notes that the April 2001 VA examiner found that the veteran had "good" muscle tone and bulk. Thus, the objective evidence does not show that any additional functional loss the veteran may experience due to fatigue is more severe than what is already contemplated in a 20 percent rating under Diagnostic Code 5292. Accordingly, the Board finds that the veteran's low back disability does not more nearly approximate the criteria associated with a 40 percent rating under Diagnostic Code 5292. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2004); 38 C.F.R. § 4.71a, Diagnostic 5292 (2003). Under Diagnostic 5293 (in effect prior to September 23, 2002), a 40 percent rating is prescribed for severe intervertebral disc syndrome with recurring attacks and intermittent relief. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2002). A 60 percent rating is prescribed for pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, and little intermittent relief. Id. The veteran is currently diagnosed with degenerative disc disease, and he complains of low back pain with radiculopathy to the right groin area and leg. The April 2001 VA examination also revealed a positive SLR test. According to the October 2002 electrodiagnostic evaluation, however, there is no electrodiagnostic evidence of lumbar radiculopathy, myopathy, or polyneuropathy. VA treatment records similarly show that despite degenerative disc disease at L4/L5 and L5/S1, at this time, there is no evidence of lumbar radiculopathy, myopathy, or polyneuropathy. Despite the positive MRI findings, it was the opinion of Dr. R.P.B. that the neurologic exam was "pretty normal." Dr. R.P.B. also noted that the veteran's symptoms seemed more like a strain. Thus, while the veteran may meet one of the criterion associated with a 60 percent rating under Diagnostic Code 5293 (demonstrable muscle spasms), the veteran's low back disability does not more nearly approximate the criteria associated with a 60 percent rating or a 40 percent rating in the absence of other neurologic manifestations appropriate to the site of the diseased discs. Accordingly, the veteran is not entitled to a rating in excess of 20 percent under Diagnostic Code 5293. 38 C.F.R. § 4.71a, Diagnostic 5293 (2002). In regard to other potentially applicable diagnostic codes, the Board notes that the medical evidence shows that the veteran does not have ankylosis of the lumbar spine. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (defining ankylosis as stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint). Moreover, the veteran's service-connected low back disability is not analogous to an individual with ankylosis of the lumbar spine. To the contrary, the medical evidence shows that the veteran has functional range of motion in the lower spine. Thus, the veteran is not entitled to a compensable rating under Diagnostic Code 5289 for favorable or unfavorable ankylosis of the lumbar spine, much less a 40 percent rating The remaining diagnostic codes are not applicable. Thus, the veteran is not entitled to a rating in excess of 20 percent under any other potentially applicable diagnostic codes. In regard to a separate rating for x-ray evidence of degenerative arthritis, under Diagnostic Codes 5010-5003, traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2003-2004). That rating may not be combined with other ratings based on limitation of motion of the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, Note (1) (2003-2004). The Board notes that no physical manifestations attributable to the arthritic findings have been identified that are not already accounted for in the current rating (limitation of lumbar spine motion, pain, fatigue, muscle spasms) and that would not violate the rule against pyramiding. See 38 C.F.R. § 4.14 (2003-2004) (providing that the evaluation of the same disability under various diagnoses is to be avoided). Thus, a separate rating for degenerative joint disease at L4/5 under Diagnostic Code 5003 is not in order. Accordingly, under the old schedule for rating spine disabilities, the Board finds that the veteran's service- connected chronic low back strain more closely approximates the criteria associated with the currently assigned 20 percent rating under Diagnostic Code 5295, prior to September 23, 2002. Moreover, the veteran is only entitled to a single 20 percent rating for the orthopedic and neurologic manifestations of his low back disability. Diagnostic Code 5293 contemplates loss of range of motion because the nerve defects and resulting pain associated with injury to the sciatic nerve may cause limitation of motion of the cervical, thoracic, or lumbar vertebrae. VAOPGCPREC 36-97. For this reason, prior to September 23, 2002, the veteran may not receive separate ratings for his orthopedic and neurologic manifestations of his low back disability as to do so would constitute pyramiding. 38 C.F.R. § 4.14 (2003-2004). C. New Schedule for Rating Intervertebral Disc Syndrome- From September 23, 2002 to September 25, 2003 Effective September 23, 2002, the diagnostic criteria for intervertebral disc syndrome under Diagnostic Code 5293 was revised. As revised, prior to September 25, 2003, Diagnostic Code 5293 provides that intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either based on the (1) total duration of incapacitating episodes over the past 12 months or by (2) combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003). Under Diagnostic Code 5293, in effect from September 23, 2002 to September 25, 2003, a 10 percent rating is assigned for incapacitating episodes of intervertebral disc syndrome having a total duration of at least one week but less than two weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003). A 20 percent rating is assigned for episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. Id. A 40 percent rating is assigned for episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Id. A 60 percent rating is assigned for episodes having a total duration of at least six weeks during the past 12 months. Id. Note (1) to the new version of Diagnostic Code 5293 defines an "incapacitating episode" as "a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." "Chronic orthopedic and neurologic manifestations" were defined as "orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so." In regard to the first evaluation method, the medical evidence of record shows that at no time had a physician prescribed the veteran bed rest and treatment for a certain duration of time at any time during the appeal period. At the July 2004 travel board hearing, the veteran denied that any doctor ever prescribed bed rest for him. Thus, the veteran is only entitled to a noncompensable rating under the first evaluation method. In regard to the second evaluation method, the chronic orthopedic manifestation associated with the veteran's service-connected chronic low back strain is limitation of lumbar spine motion. As previously discussed, the Board finds that the veteran is entitled to no more than 20 percent under Diagnostic Code 5295 (lumbosacral strain). Incidentally, the Board notes that a 20 percent rating under Diagnostic Code 5295 contemplates demonstrable muscle spasms. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2003). The Board similarly found that the veteran was entitled to no more than 20 percent under Diagnostic Code 5292 for moderate limitation of lumber spine motion with functional loss due to pain and fatigue on prolonged use. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2003). Thus, a 20 percent rating for orthopedic manifestations of the veteran's low back disability is for application. In regard to neurologic manifestations, the veteran complains of radiculopathy of low back pain to the right groin area and leg. Thus, the potentially relevant Diagnostic Code sections are Diagnostic Code 8520, for the sciatic nerve, Diagnostic Code 8526, for the anterior crural nerve (femoral), Diagnostic Code 8527, for the internal saphenous nerve, Diagnostic Code 8528, for the obturator nerve, Diagnostic Code 8529, for the external cutaneous nerve of thigh, and Diagnostic Code 8530, for the ilio-inguinal nerve. 38 C.F.R. § 4.124a, Diagnostic Codes 8520, 8526, 8527, 8528, 8529, 8530 (2003-2004). The medical evidence shows that no diagnosis has been made that the veteran suffers from incomplete or complete paralysis of any of the foregoing nerves or any other disease of the peripheral nerves attributable to the service-connected low back disorder. Moreover, as previously discussed, electrodiagnostic testing revealed no evidence of lumbar radiculopathy, myopathy, or polyneuropathy. Thus, the veteran's disability does not meet the rating criteria for any of the aforementioned diagnostic codes. Notwithstanding the foregoing, as previously noted, the April 2001 VA examiner specifically attributed the veteran's muscle spasms as due, in part, to degenerative disc disease at L4/5 and L5/S1. A muscle spasm, in and of itself, is not necessarily an indicator of neurological deficit. Yet, where as here, it has been associated as a residual of degenerative disc disease, this medical evidence allows for a finding of a minimal disability rating for a disability that nearly approximates incomplete paralysis of the appropriate nerve. As the medical evidence shows that no actual nerve is affected by the veteran's low back disability, the Board will simply apply the Diagnostic Code affording the highest possible rating evaluation for "mild" neurological symptoms. In this manner, the Board satisfies its obligation to resolve all reasonable doubt in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3 (2003-2004). In the instant case, a 10 percent rating for mild disability is afforded under Diagnostic Codes 8520 and 8526. All remaining potentially relevant Code sections provide noncompensable evaluations. As between Diagnostic Code 8520 and Diagnostic Code 8526, a higher maximum evaluation is provided under Diagnostic Code 8520. Thus, the Board finds that it is appropriate at this time to assign the veteran a 10 percent rating under Diagnostic Code 8520 for the neurologic manifestations of the low back disability. Lastly, the Board notes that the amended schedule provides that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be evaluated on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5293, Note (3) (2003). The medical evidence shows that there are degenerative changes at L4/L5 and L5/S1. The medical evidence, however, does not show that the effects in each spinal segment are clearly distinct. Thus, the medical evidence does not show that evaluation of each segment of the lumbar spine should be made at this time. In sum, as instructed by the revised version of Diagnostic Code 5293 in effect from September 23, 2002 to September 25, 2003, the Board has considered the chronic orthopedic and neurologic manifestations of the veteran's service-connected low back disability. It has been determined that the veteran is entitled to a 20 percent rating under Diagnostic Code 5292 for his orthopedic manifestations, and that he is entitled to a 10 percent rating under Diagnostic Code 8520 for the neurologic manifestations. Those separate orthopedic manifestation and neurologic manifestation ratings must now be combined under 38 C.F.R. § 4.25, along with all other service-connected disabilities. The veteran is also service- connected for bursitis of the left shoulder, for which he is assigned a 10 percent rating. Applying the Combined Ratings Table of 38 C.F.R. § 4.25 to the veteran's ratings of 20 percent (orthopedic manifestations of his low back disability), 10 percent (neurologic manifestations of his low back disability), and 10 percent (bursitis of the left shoulder), an evaluation of 40 percent is derived. The combined rating result of 40 percent under the second method for evaluating intervertebral disc syndrome clearly exceeds any combined rating result under the first evaluation method, where the veteran is not entitled to a compensable rating for incapacitating episodes of intervertebral disc syndrome. Thus, the revised version of Diagnostic Code 5293 in effect from September 23, 2002 to September 25, 2003, entitles the veteran to an increased combined service-connected disability evaluation of 40 percent if he is rated separately for the orthopedic and neurologic manifestations of the low back disability. As such, the evidence supports the grant of a separate 20 percent rating for the orthopedic manifestations of the low back disability, and a separate 10 percent rating for the neurologic manifestations of the low back disability, for the period from September 23, 2002 to September 25, 2003. D. General Rating Formula for Diseases and Injuries of the Spine- From September 26, 2003 Finally, the diagnostic criteria pertinent to spinal disabilities in general were revised effective September 26, 2003 (as codified in relevant part at 38 C.F.R. § 4.71, Diagnostic Codes 5235-5243 (2004)). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2004). A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. Normal range of flexion, extension, lateral flexion, and lateral rotation motion of the thoracolumbar spine was previously detailed under the Board's 'Old Schedule for Rating Spine Disabilities' analysis. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a, Note (2) (2004). The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. At its worst, with pain, the veteran's lumber spine demonstrated forward flexion between 30 degrees and 60 degrees (at 40 degrees) at the April 2001 VA examination. As the foregoing medical finding does not support a 40 percent evaluation for forward flexion 30 degrees or less under the General Rating Formula for Diseases and Injuries of the Spine, the veteran is not entitled to a rating in excess of 20 percent thereunder. In making this determination, the Board considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, which address additional functional loss due to pain, weakness, excessive fatigability, etc. As previously discussed when the Board evaluated the veteran's low back disability under the old schedule for rating spine disabilities, 'forward flexion limited to 40 degrees during flare-ups on account of pain' best reflected the veteran's overall disability picture when the examination findings noted in the April 2001 VA examination report, Dr. J.T.H.'s September 2002 report, and Dr. R.P.B.'s October 2002 report were weighed against each other. With respect to the veteran's complaints of fatigue, the Board reiterates that the April 2001 VA examiner found that the veteran had "good" muscle tone and bulk. There is no medical evidence of record contrary to this finding. There is also no ankylosis of the lumbar spine, and for reasons previously discussed, the low back disability is not analogous to an individual with ankylosis of the lumbar spine. Moreover, segments of the thoracic spine are not service-connected. Accordingly, the Board finds that the veteran's low back disability more nearly approximates the criteria associated with a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2004). In regard to other potentially applicable diagnostic codes under which the veteran may be entitled to a rating in excess of 20 percent, the new schedule effective from September 26, 2003 provides that intervertebral disc syndrome (preoperatively or postoperatively) (Diagnostic Code 5243) is now to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. The rating criteria for intervertebral disc syndrome based on incapacitating episodes remain the same as those effective September 23, 2002, as outlined above. As discussed above, the preponderance of the evidence is against a compensable evaluation for the low back disability based on incapacitating episodes of intervertebral disc syndrome. Similarly, the competent medical evidence of record is against an evaluation in excess of 20 percent for the low back disability based on the General Rating Formula for Diseases and Injuries of the Spine. The Board notes that a 20 percent rating may be assigned for the requisite limitation in range of lumbar spine motion and/or muscle spasms under the General Rating Formula for Diseases and Injuries of the Spine. Note (1) there under provides that VA must evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. For reasons previously discussed, the veteran's muscle spasms may be characterized as a mild neurologic manifestation of his low back disability. Thus, the veteran is entitled to a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine for limitation in forward flexion to 40 degrees and he is entitled to a separate 10 percent rating under Diagnostic Code 8520 for mild neurological symptoms of the low back disability. Clearly, under Diagnostic Code 5243 (intervertebral disc syndrome), evaluating the veteran's low back disability under the General Rating Formula for Diseases and Injuries of the Spine rather than under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Accordingly, a 20 percent rating under Diagnostic Code 5243 is assigned, and a separate 10 percent rating under Diagnostic Code 8520 is assigned, both effective from September 26, 2003. E. Extraschedular Rating The Board notes that there is no evidence of record that the veteran's service-connected chronic low back strain causes marked interference with employment (i.e., beyond that already contemplated in the assigned evaluation), or necessitated any frequent periods of hospitalization, such that application of the regular schedular standards is rendered impracticable. The Board notes that there are no medical records that show frequent periods of hospitalization on account of the low back disability. Also, the veteran presented sworn testimony at the July 2004 travel board hearing that he was currently employed. The Board emphasizes that the percentage ratings assigned by the VA Schedule for Rating Disabilities represent the average impairment in earning capacity resulting from a service-connected disability. 38 C.F.R. § 4.1 (2004). In the instant case, to the extent that the veteran's service-connected low back disability interferes with his employability, the currently assigned ratings adequately contemplate such interference, and there is no evidentiary basis in the record for a higher rating on an extraschedular basis. There is no competent evidence that the veteran is unable to secure or follow a substantially gainful occupation solely as a result of his service-connected low back disability. Hence, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) (2004) for assignment of an extraschedular evaluation. Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). ORDER Service connection for a disorder as a result of asbestos exposure is denied. Service connection for post-traumatic stress disorder is denied. Service connection for anxiety disorder or dysthmia is denied. A rating in excess of 20 percent for service-connected chronic low back strain, prior to September 23, 2002, is denied. A separate rating of 20 percent for orthopedic manifestations of the service-connected chronic low back strain, from September 23, 2002 to September 25, 2003, is granted, subject to the law and regulations controlling the award of monetary benefits. A separate rating of 10 percent for neurologic manifestations of the service-connected chronic low back strain, from September 23, 2002 to September 25, 2003, is granted, subject to the law and regulations controlling the award of monetary benefits. A separate rating of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine for the service-connected chronic low back strain, from September 26, 2003, is granted, subject to the law and regulations controlling the award of monetary benefits. A separate rating of 10 percent for neurologic abnormalities of the service-connected chronic low back strain, from September 26, 2003, is granted, subject to the law and regulations controlling the award of monetary benefits. REMAND The Board notes that the RO's correspondence to the veteran dated in August 2003, which purported to apprise the veteran of VA's duties under the VCAA and the delegation of responsibility between VA and the veteran in procuring the evidence relevant to his left knee claim, must be corrected. As previously discussed in the INTRODUCTION portion of this decision, in light of the VCAA, the RO reopened the left knee claim in the July 2002 rating decision, which had been previously disallowed as not well-grounded. The August 2003 VCAA erroneously provides the veteran with notice of the information and evidence necessary to substantiate a "new and material evidence" claim. Thus, the veteran must be provided with a corrected VCAA notice to reflect the information and evidence necessary to substantiate a "service connection " claim. At the RO hearing and travel board hearing, the veteran testified that he injured his left knee in Panama in 1985 during a period of active duty for training. He maintained that he did not obtain treatment for his knee until after he returned to the United States from Panama. He testified that he currently experienced multiple problems with his left knee. The reserve service medical records show that the veteran was seen in the Emergency Care and Treatment unit on January 19, 1986 for complaints of a left knee injury that reportedly occurred around December 19, 1985. The veteran reported that he injured his left knee in Panama approximately one month ago. The physical examination was negative, but the examiner noted an assessment of probable left knee sprain. The examiner referred the veteran for a consultation. A January 21, 1986 consultation sheet showed that the veteran reported again that he injured his left knee approximately one month ago during a period of reserve active duty for training. The physical examination was negative, but the examiner noted an assessment of probable strain/contusion. Prior to January 19, 1986, service medical records covering the veteran's first period of service show that the veteran complained of pain behind his knee and calf in August 1975. No assessment was provided. The veteran was discharged from active service. Reserve service medical records are significant for complaints of left knee pain in July 1981, during which time a physical examination revealed tenderness along the medial joint line. The examiner diagnosed synovitis of the left knee, etiology unknown. In November 1985, the veteran complained of left knee pain with no known injury. The physical examination revealed some tenderness over the left knee with associated crepitation. The examiner diagnosed chondromalacia of the left patella. After the January 19, 1986/January 21, 1986 emergency room visit, service medical records covering the veteran's second period of service are significant for complaints of left knee pain and chronic ache over the knee cap in December 1990. The veteran reported the history of a left knee injury in Panama in 1985. The examiner noted an assessment of chronic knee pain. A January 1993 examination report shows that no left knee disorder was identified, but on the Report of Medical History, the veteran complained that his left knee had ached after exercising for the past four to five years. The March 1998 VA joints examination report showed that a physical examination revealed crepitance, hyperextension, and medial laxity in the left knee, although the same was noted in the right knee. The above-discussed evidence shows that additional information and evidence is necessary in order to substantiate the veteran's claim, thereby triggering VA's duty to assist the veteran in substantiating his claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2004). Complaints of left knee pain are noted during the veteran's first period of active service, during his reserve service, and during his second period of active service. With respect to the veteran's reserve service, AMC must verify whether the veteran served on any periods of active duty for training or inactive duty training from July 1976 to September 1986, for purposes of determining whether any dates of treatment for the left knee coincide with periods the veteran served on active duty for training or inactive duty training. Also, it is not clear from the medical evidence as to whether the veteran has a current chronic left knee disability that had its onset during a period of his service. Therefore, AMC must afford the veteran a VA examination and obtain a medical opinion for purposes of determining the identity of any left knee disorder that may be present and whether any left knee disorder found on examination is related to any symptomatology shown in service. Accordingly, this case is REMANDED to the RO via the AMC for the following action: 1. Please send the veteran a new VCAA notice that advises him of the evidence needed to substantiate a claim of service connection for the left knee disorder in accordance with the notification requirements of 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2004). 2. Please verify whether the veteran served on any periods of active duty for training or inactive duty training from July 1976 to September 1986. 3. The veteran should be afforded an appropriate medical examination to ascertain the identity and etiology of any left knee disorder that may be present. All indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer an opinion as to whether any left knee disorder found on examination is at least as likely as not related to any symptomatology shown in service. Please send the claims folder to the examiner for review in conjunction with the examination. 4. Thereafter, the veteran's claim should be readjudicated with consideration of all the evidence of record. If any benefit sought on appeal remains denied, the veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response by the veteran and his representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The purpose of this REMAND is for additional development and to ensure due process. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the regional office. 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 The Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). ______________________________________________ John E. Ormond, Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs