Citation Nr: 0809755 Decision Date: 03/24/08 Archive Date: 04/09/08 DOCKET NO. 97-15 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a genitourinary disorder, claimed as kidney disease and/or a disability manifested by hematuria. 2. Entitlement to service connection for a bilateral shoulder disorder, to include as secondary to service- connected postoperative residuals of left wrist fracture. 3. Entitlement to service connection for a low back disorder, to include as secondary to service-connected postoperative residuals of left wrist fracture. 4. Entitlement to service connection for depression, to include as secondary to service-connected bronchial asthma or postoperative residuals of a left wrist fracture. 5. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity, to include as secondary to service-connected postoperative residuals of a left wrist fracture. 6. Entitlement to ratings in excess of 30 percent for bronchial asthma prior to September 27, 2006, and in excess of 60 percent from September 27, 2006. 7. Entitlement to an increased rating for postoperative residuals of a left wrist fracture, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Brian J. Milmoe, Counsel INTRODUCTION The veteran served on active duty from March 1968 to March 1972. This matter was most recently before the Board of Veterans' Appeals (Board) in May 2006, at which time it was determined that new and material evidence had been received to reopen a previously denied claim of entitlement to service connection for a low back disorder and the veteran's reopened claim therefor, as well as the other issues identified on the title page of this document, were remanded to the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, through the VA's Appeals Management Center (AMC) in Washington, DC. The purpose of such remand was to permit the AMC to undertake certain procedural and evidentiary development. Following the AMC's attempts to complete the requested actions, the case has been returned to the Board for further review. Notice is taken that, while the case remained in remand status, the AMC by its rating decision of May 2007 increased the schedular evaluation for the veteran's bronchial asthma from 30 percent to 60 percent, effective from September 27, 2006. The appeal of this claim continues because a decision awarding a higher rating, but less that the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The issue on appeal, as reflected on the title page of this document, has been appropriately modified to reflect the aforementioned action of the AMC. The issues of the veteran's entitlement to direct and secondary service connection for carpal tunnel syndrome of the left upper extremity and for secondary service connection for right shoulder and low back disorders are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC. FINDINGS OF FACT 1. The veteran was evaluated and treated for genitourinary symptoms during service, to include hematuria and there is a medical opinion that it was likely that he had renal stone disease during that time; however, there is no competent evidence of a nexus between a current genitourinary disorder and service; the most recent examination ruled out a current diagnosis of a kidney disease or a disability manifested by hematuria; the medical evidence shows that the only current genitourinary disorder, benign prostatic hypertrophy is not linked to service. 2. The medical evidence does not show disability of either shoulder during service or for many years thereafter; there is no competent evidence linking a current right shoulder disorder to service and there is no medical or X-ray evidence of a current left shoulder disability. 3. The service medical records show that the veteran was evaluated and treated for back symptoms, to include pain and spasm; however, his separation from service examination of the spine was normal and there is no post-service medical evidence of a back disability, to include arthritis of the lumbar spine, until many years after service; current disability of the low back is not demonstrated to be related to service or any event thereof. 4. There is no competent evidence that links a post-service diagnosis of depression to service; the most recent psychiatric examination ruled out a current diagnosis of the claimed psychiatric disorder. 5. The veteran's service-connected bronchial asthma was not more than mild prior to September 27, 2006, and not manifested by pronounced disability thereafter with very frequent asthmatic attacks and severe dyspnea on slight exertion between attacks and with marked loss of weight or other evidence of severe impairment of health; pulmonary function testing revealed a forced expiratory volume at one second (FEV-1) or a ratio of FEV-1 to forced vital capacity (FVC) of more than 55 percent prior to September 27, 2006, and less than 55 percent subsequent thereto. 6. The veteran's service-connected postoperative residuals of the left (nondominant) wrist are currently manifested by limited range of motion without ankylosis or radial impairment; the maximum rating for limitation of wrist motion had been assigned. 7. An exceptional or unusual disability picture involving frequent periods of hospital care or a marked interference with employment is not shown as to the veteran's service- connected bronchial asthma or postoperative residuals of a fracture of the left wrist. CONCLUSIONS OF LAW 1. A genitourinary disorder, to include kidney disease and a disability manifested by hematuria, was not incurred in or aggravated by active service, nor may nephritis or calculi of the ureter be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2007). 2. A bilateral shoulder disorder was not incurred in or aggravated by active service, nor may arthritis of either shoulder be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2007). 3. A low back disorder was not incurred in or aggravated by active service, nor may arthritis of the lumbar spine be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2007). 4. Claimed depression was not incurred in or aggravated by active service, nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.310, as in effect prior to October 10, 2006; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2007). 5. The criteria for the assignment of a rating in excess of 30 percent for bronchial asthma prior to September 27, 2006, and in excess of 60 percent for bronchial asthma on and after September 27, 2006, have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.97, Diagnostic Code 6602, as in effect prior to October 7, 1996; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6602 (2007). 6. The criteria for the assignment of a rating in excess of 10 percent for postoperative residuals of a fracture of the left (nondominant) wrist have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5214, 5215 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Considerations As noted above, this matter was previously remanded by the Board in May 2006, and on a prior occasion, in order to facilitate the conduct of additional evidentiary and procedural development. All of the actions previously sought by the Board through its prior development requests appear to have been completed in full as to the issues herein addressed on their merits, and it is of note that neither the veteran, nor his representative, contends otherwise. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Under the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000), VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. 38 U.S.C.A. § 5102; 38 C.F.R. § 3.159(b)(2). Second, VA has a duty to notify the appellant of the information and evidence needed to substantiate and complete a claim, notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This assistance includes obtaining all relevant evidence adequately identified in the record, and in some cases, affording VA examinations. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Finally, VA has a duty to notify the appellant that he or she should submit all pertinent evidence in his possession. During the pendency of this appeal, a decision was entered by the United States Court of Appeals for Veterans Claims (Court) in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran's status; 2) existence of disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. For an increased-compensation claim, 38 U.S.C.A. § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, No. 05-0355, (U.S. Vet. App. Jan. 30, 2008). Further, if the Diagnostic Code (DC) under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant DCs, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation, e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, slip op. at 5-6. In this case, the Board finds that there is no issue as to providing an appropriate application form or completeness of the application. Written notice of the information and evidence needed by the veteran-appellant to substantiate and complete his claims, notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain for the appellant was provided to him through the AMC's VCAA letter of May 2006. The appellant was thereby notified that he should submit all pertinent evidence in his possession and he was furnished the notice required under Dingess-Hartman. VCAA notice is to be furnished to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the initial VCAA notice letter was prepared and furnished to the veteran-appellant long subsequent to the RO's rating decisions in 1996 and 1997. Where the VCAA notice is defective, the Board must presume that the error was prejudicial, and VA bears the burden of rebutting said presumption. Sanders v. Nicholson, 487 F.3d 881 (2007) (recognizing that "VCAA notice errors are reviewed under a prejudicial error rule" and holding that "all VCAA notice errors are presumed prejudicial and . . . VA has the burden of rebutting this presumption"); see also Mayfield v. Nicholson, 19 Vet. App. 103, 111-16 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In Sanders, the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial and that once an error is identified by the Veterans Court (Court of Appeals for Veterans Claims), the burden shifts to VA to demonstrate that the error was not prejudicial. The Federal Circuit reversed the Court of Appeals for Veterans Claims' holding that an appellant before the Court has the initial burden of demonstrating prejudice due to VA error involving: (1) providing notice of the parties' respective obligations to obtain the information and evidence necessary to substantiate the claim: (2) requesting that the claimant provide any pertinent evidence in the claimant's possession; and (3) failing to provide notice before a decision on the claim by the agency of original jurisdiction. An error "whether procedural or substantive, is prejudicial when [it] affects a substantial right so as to injure an interest that the statutory or regulatory provision involved was designed to protect such that the error affects 'the essential fairness of the [adjudication].'" Mayfield, supra, at 116; accord Sanders, supra, at *10 ("this opinion does not . . . change the rule that reversal resulted the essential fairness of the adjudication to have been affected"). That is, "the key to determining whether an error is prejudicial is the effect of the error on the essential fairness of the adjudication." Id.; accord Sanders, supra. To show that the error did not affect the essential fairness of the adjudication, VA must demonstrate that the purpose of the notice was not frustrated, such as by demonstrating: (1) That any defect was cured by actual knowledge on the part of the claimant, see Vazquez-Flores, slip op. at 12 ("(a)ctual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.") (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)); (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 F.3d at 889. Additionally, consideration also should be given to "whether the post- adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre- adjudicatory section 5103(a) notice error non-prejudicial." Vazquez-Flores, slip op. at 9. The record in this instance demonstrates that full VCAA notice was effectuated prior to the issuance of supplemental statements of the case by the AMC in August and September 2007. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and readjudicating the claim in the form of an SOC to cure timing of a notification defect). More timely VCAA notice would not have operated to alter the outcome of the issues on appeal, in view of the fact that the record does not demonstrate a factual predicate for entitlement to service connection for genitourinary, bilateral shoulder, or low back disorders, or depression, on a direct basis, or for secondary service connection for a right shoulder disorder or depression, or increased ratings for asthma or a left wrist disorder. Sanders, supra (recognizing that "a demonstration that the outcome would not have been different in the absence of the error would demonstrate that there was no prejudice"). In view of the foregoing, the Board cannot conclude that any defect in the timing of the notice provided affected the essential fairness of the adjudication, and, thus, the presumption of prejudice is rebutted. Id. As well, the record in this instance demonstrates that the veteran has been provided the diagnostic criteria utilized by VA for the rating of his service-connected asthma and left wrist fracture. His allegations with respect to the inadequacy of the current ratings and his entitlement to increased ratings for each of the disorders in question reflect actual knowledge on his part of the applicable rating criteria. In view of the foregoing, the Board cannot conclude that any defect in the substance or timing of the notice provided affected the essential fairness of the adjudication, and, thus, the presumption of prejudice is rebutted. Id.; see Bernard v. Brown, 4 Vet. App. 384 (1993). Also, all pertinent examination and treatment records have been obtained and made a part of the claims folder to the extent that such records have been adequately identified or are otherwise available. Notice is taken that record contains the veteran's service medical records, as well as a variety of medical records compiled by examining and treating medical professionals, including reports from multiple VA medical examinations, and other evidence. As applicable to the matters herein addressed on their merits, the VA medical examinations were comprehensive in scope and productive of detailed medical findings with which to rate the disabilities in question and to address matters involving date of onset and etiology of the claimed disabilities. The record is otherwise found to be fully adequate for consideration of the merits of the issues herein addressed and there is no need for the conduct of any additional medical evaluation by VA or solicitation of any further medical opinion. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Accordingly, it is found that VA has satisfied its duties under the VCAA. Claims for Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Where a veteran served 90 days or more during a period of war, or during peacetime after December 31, 1946, and a chronic disease, such as arthritis, nephritis, or calculi of the kidney or bladder, becomes manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. When the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support a claim of service connection. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Alternatively, the nexus between service and the current disability can be satisfied by medical or lay evidence of continuity of symptomatology and medical evidence of a nexus between the present disability and the symptomatology. See Voerth v. West, 13 Vet. App. 117 (1999); Savage v. Gober, 10 Vet. App. 488, 495 (1997). Generally, secondary service connection may be granted when a nonservice-connected disability is proximately due to or the result of a service- connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (when a veteran's service-connected disability aggravates, but is not the proximate cause of, a nonservice-connected disability, the veteran is entitled to compensation for that incremental increase in severity of the nonservice-connected disability attributable to the service-connected disability). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen, supra. See 71 Fed. Reg. 52744 (2006). That amendment requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. Although such amendment has not been considered by the RO with respect to the claims for secondary service connection for depression and carpal tunnel syndrome of the left upper extremity, remand to permit readjudication on that basis is unnecessary in view of the fact that no current disability as to either depression or carpal tunnel syndrome of the left upper extremity is demonstrated. Parenthetically, it is noted that consideration of the amended version of 38 C.F.R. § 3.310 is sought by the remand below regarding the other claims for secondary service connection herein on appeal. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also, 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The veteran does not allege, nor does the record show, that the disabilities for which service connection is claimed are the result of an event occurring while he engaged in combat with the enemy. As such, the provisions of 38 U.S.C.A. § 1154 (West 2002) are not for application in this instance. Even were that statute applicable to the facts of this case, it is noted that 38 U.S.C.A. § 1154(b) does not address the questions of the existence of a present disability or of a nexus between such disability and service, both of which are required for a grant of service connection. The veteran was afforded an RO hearing in August 1997, when he testified that he slipped and fell in service, causing multiple orthopedic injuries, including to his wrist, low back, and shoulder, as well as genitourinary problems involving frequent hematuria. Inservice medical treatment was received for those injuries and it is noted by the veteran that a grant of service connection for a left wrist fracture sustained in the aforementioned mishap has already been established. Genitourinary Disorder, to include Kidney Disease or a Disability Manifested by Hematuria Service medical records disclose that treatment was sought by the veteran on several occasions in 1970 and again in early 1971 and early 1972 due to hematuria. Examination during a July 1970 hospitalization revealed moderate enlargement of the prostate, with bogginess, but without tenderness or nodules. In-service diagnoses of uretal calculi and chronic prostatitis are also indicated. Following the veteran's discharge from service in March 1972, however, more than twenty years elapsed prior to a showing in December 1992 of mild prostatic hypertrophy. An intravenous pyelogram at that time disclosed normal kidneys and ureters, with trabecular thickening of the bladder which was then noted to be due possibly to chronic outlet obstruction. Further evaluation in February and March 1994 yielded clinical assessments of urinary retention, secondary to mild benign prostatic hypertrophy (BPH) and "symptomatic hematuria". Of record is a statement, dated in May 1997, from the veteran's former spouse. Therein, she recalled that the veteran had experienced blood in his urine during the 1970s and early 1980s. Beginning in June 1997, the veteran was treated for complaints of urinary difficulties and impotence. In July 1997, probable sphincter dyssynergia was diagnosed. Other medical treatment was received in December 1998 for obstructive voiding symptoms and early BPH, and in June 2001 for BPH. A renal ultrasound at that time was interpreted to be normal. In order to better assess the nature and etiology of the veteran's claimed genitourinary disorder, the Board remanded this matter in May 2006 in order to facilitate the conduct of a VA medical examination and the preparation of a medical opinion as to the relationship between in-service genitourinary problems and any genitourinary disorders that might currently be present. Such examination was performed in September 2006 and yielded a diagnosis of hematuria due to nephrolithiasis during service, currently inactive; prostatitis in service, treated, resolved; current genitourinary condition diagnosed as BPH, with such being less likely than not a residual of any in-service renal or prostate disease. Based on the examiner's review of the evidence on file, inclusive of service medical records and the medical data developed after service, it was concluded that the veteran's only currently diagnosed genitourinary disorder, that of BPH, was less likely than not due to or caused by any urinary tract condition that had its onset during military service. The examiner noted that the veteran's BPH had resulted in a slow urinary stream, incomplete voiding, and sexual dysfunction and that service medical records did not indicate any recurrent requirement to treat prostatitis during service, nor was it the case that the veteran's prostatitis was a precursor to, or a cause of, his BPH. While the existence of genitourinary abnormalities in service is shown, the presence of chronic disability related thereto is not demonstrated. There was a single in-service assessment of chronic prostatitis but this was recorded decades ago and, in any event, the most recent genitourinary examination specifically ruled out a current diagnosis of prostatitis or residuals of same. Moreover, more than twenty years elapsed following the veteran's discharge from service before the existence of BPH is shown and the only competent opinion that addresses the nexus to service question weighs against such a contended causal relationship. To the extent that the veteran is now contending that he had genitourinary symptoms continually or on an intermittent basis after service, his contention is outweighed by the negative post- service medical evidence. See Maxon v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]; see also Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002) ["negative evidence" could be considered in weighing the evidence]. Likewise, there is medical evidence, not otherwise contradicted, to the effect that any in-service genitourinary problem of the veteran, inclusive of hematuria, ureteral calculi, or prostatitis, bears no relationship to the only current genitourinary disability, that of BPH. No other medical findings or competent opinions are presented with which to identify a nexus between the veteran's in-service genitourinary problems and current disability of his genitourinary system. Any opinion of the veteran as to medical diagnosis or etiology regarding his claimed genitourinary disorder is deemed incompetent, in the absence of a showing that he is in possession of the necessary medical background or training. Espiritu, surpa. To elaborate on the veteran's lay statements, he can attest to factual matters of which he had first-hand knowledge, e.g., experiencing pain or urinary symptoms during and after service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the veteran as a lay person has not been shown to be capable of making medical conclusions, thus, his statements regarding causation are not competent. Espiritu, supra. Accordingly, while the veteran is competent to report what comes to him through his senses, he does not have medical expertise to provide a competent opinion regarding diagnosis and causation. See Layno v. Brown, 6 Vet. App. 465 (1994). In light of the foregoing, the Board finds that a preponderance of the evidence is against the veteran's claim for service connection for a genitourinary disorder. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); see also, generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Bilateral Shoulder Disorder Service medical records are entirely negative for complaints or findings involving a disorder of either of the veteran's shoulders. Following service discharge, complaints of shoulder problems were initially documented in September 1978. A magnetic resonance imaging (MRI) in August 1992 disclosed a right shoulder impingement syndrome with tendionpathy of the supraspinatus; no evidence of a tear was shown. When evaluated in August 1994, the veteran noted that he had injured his right shoulder in 1992 when lifting a wooden pallet; range of motion of the right shoulder was at that time within normal limits and there was no evidence of inflammation. In July 1995, there was shown to be right shoulder impingement that was tied to post-service shoulder injuries in 1987 and 1992. A history of shoulder injuries in 1987 and 1992 was reiterated by the veteran in 1997, when there was medically noted to be right shoulder tendinitis and rotator cuff impairment. Additional treatment for variously diagnosed right shoulder problems followed, inclusive of right subacromial bursitis. There is no showing of a current diagnosis of a left shoulder. Service connection may not be granted unless a current disability exists. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Accordingly, the claims advanced for direct and secondary service connection for a left shoulder disorder must fail. Id. See also 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.310; Boyer; Mercado-Martinez, supra; Allen, supra. Notice is taken that no medical professional offers any finding or opinion specifically linking any existing shoulder disorder to the veteran's period of military service or any event thereof. The only medical professional speaking to that issue provides an opinion contraindicating entitlement to direct service connection for a shoulder disorder. Specifically, it is noted that a VA medical examination was afforded the veteran in September 2006, when he reported to the examiner that he was seeking service connection only for his right shoulder disability. Findings from clinical examination and testing resulted in entry of a diagnosis of current disability of tendinopathy of the right shoulder and it was the examiner's opinion that it was less likely than not that such disorder began in service or was causally related to any incident occurring during active service. Review of the record by the examiner showed that the veteran's right shoulder disorder was more likely than not the result of an industrial injury in 1992 and repetitive use of his right shoulder in the performance of his job duties during a fairly long civilian career. In all, the veteran's allegation of an inservice injury to one or both shoulders leading to the onset of chronic disability is uncorroborated. The existence of current disability of the left shoulder is not shown, although current disablement of the veteran's right shoulder is demonstrated. Persuasive evidence that existing shoulder disability bears a nexus to the veteran's period of military service is lacking and there is competent medical opinion which discounts any linkage between current disability of the veteran's right shoulder involving tendinopathy and active service or any event thereof. As a preponderance of the evidence is against entitlement to direct service connection for a shoulder disorder, the doctrine of reasonable doubt is not applicable and this portion of the appeal must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra; Ortiz, supra. Low Back Disorder Allegations are advanced by the veteran, to the effect that he experienced right flank pain in service following a fall and that such pain represents the beginning of his existing low back disorder. Service medical records identify complaints of right flank pain in May, June, and October 1970, which were linked by attending medical personnel to gross hematuria. It was observed by an attending medical professional in July 1970 that back spasms were present, although no diagnosis of a back disorder was then recorded. Service medical records are otherwise negative for indicia of a back disorder and a separation medical examination in February 1972 was negative for any low back abnormality, notwithstanding a notation of a history of back pain. Post-service, the veteran sought and received treatment in February 1978 for complaints of low back pain related to an injury sustained when attempting to lift a grease drum. A history of prior post-service low back injuries in 1974 and 1975 was set forth. In September 1978, complaints of low back pain were made known. Further treatment, to include a period of chiropractic care, for back-related complaints was initiated during the 1990s, with entry in August 1993 of diagnoses of low back pain and a history of a back injury in July 1992. When evaluated in August 1994, an on-the-job back injury of 1987 was reported; the assessment was of back pain. In July 1995, diagnoses of a chronic low back syndrome and a probable herniated nucleus pulposus at L4-5 were entered and the attending medical professional tied such entities to post-service injuries occurring in 1987 and 1992. In a statement, dated in May 1997, the veteran's ex-spouse noted that she recalled that the veteran had complained of low back problems during the 1970s and early 1980s. Beginning in May 1997, the veteran was evaluated and treated for degenerative disc disease of the lumbar spine with associated low back pain, and at that time, reference was made to a prior back injury in 1987. An MRI in June 1997 revealed mild central disc bulging at L5-S1 and minimal changes at L4-5; X-rays identified minimal degenerative spurring. The existence of right lumbar radiculopathy was indicated, beginning in July 1997, and at that time it was reported that low back injuries had occurred previously in 1987 and 1992. Further medical treatment was received subsequently for complaints of low back pain, with entry of various diagnoses. Pursuant to the Board's request, the veteran was afforded a VA medical examination in September 2006 with respect to his claimed low back disability. Such evaluation culminated in entry of a diagnosis of degenerative disc and joint disease of the lumbosacral spine, less likely than not having onset during military service or causally related to any incident of service. The following opinion, in pertinent part, was provided by the examiner: In conclusion, [i]n my opinion, the bulk of evidence refutes the veteran's claim that his musculoskeletal low back pain had onset during military service. This opinion is based on absence of any evidence of record of ongoing musculoskeletal condition as documented in the service medical record combined with a large body of evidence indicating that the veteran's musculoskeletal back condition had onset as a series of industrial injuries occurring after military service. [The veteran] did, indeed, suffer with a back pain condition as he claims, but the available evidence indicates that this back pain was more likely that not secondary to a urologic condition most consistent with renal stone disease. It is my opinion, therefore, that this veteran's current low back condition is less likely than not caused by or secondary to any injury or illness occurring in military service. While the existence of back pain and spasm in service is shown, the existence of a chronic low back disorder is not demonstrated in service or until many years following the veteran's separation from service. Persuasive evidence is presented that the veteran's current low back disorder is unrelated to his in-service back pain and spasm and that his in-service complaints of flank pain were more consistent with his complaints of hematuria. No medical professional links the veteran's existing low back disability to his period of military service or any event thereof and there is persuasive evidence that the currently diagnosed degenerative disc and joint disease of his lumbar spine is unrelated to active duty or any in-service incident. On that basis, the evidence preponderates against the veteran's claim for direct service connection for a low back disorder. Gilbert; Ortiz, supra. Depression Service medical records are wholly negative for complaints, findings, or diagnoses of depression and there is no showing of a psychosis during the one-year period immediately following the veteran's discharge from service in March 1972. The veteran's ex-spouse has indicated that the veteran complained of depression in the 1970s and early 1980s, but the record reflects that evidence of depression was not clinically identified until March 1994, at which time a depressed affect was noted on examination. Further evidence of depression was indicated in April and August 1994, with the August 1994 clinician noting that the veteran's depression was reactive in nature. In July and September 1995, the veteran was noted by attending medical personnel to be experiencing depression in association with his low back disablement. A diagnosis of major depression of mild to moderate severity was offered in March 1996, which led in part to an award of disability benefits from the Social Security Administration. The presence of depression was further noted later in 1996, as well as in 1997 and 1998. Notwithstanding the existence of depression for a period during the 1990s, the veteran was afforded a VA psychiatric examination in June 2007, at which he denied the existence of any current psychiatric disorder, including depression. Following a review of the claims folder and the conduct of a complete mental status evaluation, the examiner recorded a diagnostic impression of a history of depression secondary to a medical condition (back pain), in remission. (Emphasis added.) The examiner specifically found that is was less likely than not that the veteran met the criteria for entry of a diagnosis of post-traumatic stress disorder. Moreover, the veteran was noted to deny any current psychiatric or mental health problems, inclusive of depression, but reported that he had previously experienced transient problems with depression related to his back pain. The veteran was noted to point out that he had been successful in finding ways to deal with his back condition. After careful consideration of the evidence presented, including the veteran's hearing testimony, it is determined that the record fails to identify the existence of a current disability involving depression and on that basis, his claims for direct service connection and as secondary to other service-connected disorders must be denied. Brammer, supra; Gilpin, supra; Rabideau, supra. See also 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.310; Boyer; Mercado-Martinez, supra; Allen, supra. And as noted in the above discussion relating to the veteran's back disability, service connection for a back disorder is not warranted. Accordingly, even if there was a current diagnosis of depression, any claim that it was secondary to a back disability would be denied as a matter of law. Claim for Increase: Bronchial Asthma Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate DCs identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Notice is taken that in Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007), the Court held that "staged ratings are appropriate for an increased-rating claim when the factual findings shown distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." The Court found no basis for drawing a distinction between initial ratings and increased- rating claims for applying staged ratings. Service connection for bronchial asthma was established by RO action in October 1972, at which time a 10 percent rating was assigned therefor under DC 6599-6602. The 10 percent rating was increased by RO action in August 1996 to 30 percent, effective from May 24, 1995, but the veteran did not timely appeal that determination and, as such, it was rendered final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.104 (2007). By rating action in May 2007, the AMC increased the schedular evaluation for bronchial asthma from 30 percent to 60 percent, effective from September 27, 2006. Consequently, the issues presented for review are whether a rating in excess of 30 percent for bronchial asthma is warranted prior September 27, 2006, and whether a rating in excess of 60 percent is warranted from September 27, 2006. The criteria for the evaluation of respiratory disorders were amended as of October 7, 1996. See 61 Fed. Reg. 46720 (1996). Because of this fact, the question arises as to which set of rating criteria applies. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (the rule of Karnas v. Derwinski, 1 Vet. App. 308 (1991), that the version most favorable to the claimant be applied when there has been a change in rating criteria has been overruled to the extent that it conflicts with authority established by the Supreme Court and United States Court of Appeals for the Federal Circuit); see also VAOPGCPREC 7-2003, 69 Fed. Reg. 25179 (2004). "[C]ongressional enactments and administrative rules will not be construed to have retroactive effect unless their language requires this result." Landgraf v. USI Film Prods., 511 U.S. 244, 272 (1994) (quoting Bowen v. Georgetown Univ. Hosp., 488 U.S. 204, 208 (1988)); Dyment v. Principi, 287 F.3d 1377, 1385 (Fed. Cir. 2002), and Bernklau v. Principi, 291 F.3d 795, 804 (Fed. Cir. 2002). Karnas has been overruled to the extent it is inconsistent with the Supreme Court's holdings. Kuzma, supra. VA's General Counsel has held that a liberalizing law would generally not have prohibited retroactive effects. If a veteran could receive a higher evaluation under the new criteria, the effect of the change would be liberalizing. Therefore, the Board will consider the claim under the old rating criteria for the entire period of the appeal, and under the new criteria from the effective date of the noted revisions. Under the criteria in effect prior to October 7, 1996, bronchial asthma warranted a 10 percent evaluation if it is mild, with paroxysms of asthmatic type breathing (high pitched expiratory wheezing and dyspnea) occurring several times a year with no clinical findings between attacks. In order to warrant the next higher evaluation of 30 percent, the disorder must have been moderate, characterized by asthmatic attacks that are rather frequent (separated by only 10-14 day intervals) with moderate dyspnea on exertion between attacks. A 60 percent evaluation was warranted if the disorder was severe, with frequent attacks of asthma, marked dyspnea on exertion between attacks, with only temporary relief by medication, and with more than light manual labor prohibited. The 100 percent rating required that the asthma be pronounced, with very frequent asthmatic attacks, severe dyspnea on slight exertion between attacks, and marked weight loss or other evidence of a severe impairment of health. 38 C.F.R. § 4.96, DC 6602 (1996). Under the new criteria, bronchial asthma warrants a 10 percent evaluation if the FEV-1 is 71 to 80 percent of the value predicted; or if the ratio of FEV-1/FVC is 71 to 80 percent; or if intermittent inhalational or oral bronchodilator therapy is required. A 30 percent evaluation is warranted if the FEV-1 is 56 to 70 percent of the value predicted; if the FEV-1/FVC ratio is 56 to 70 percent; or if intermittent inhalational or oral bronchodilator therapy is required. A 60 percent rating is assignable where the FEV-1 is 40 to 55 percent of the value predicted; if the FEV-1/FVC ratio is 40 to 55 percent; or at least monthly visits to a physician are made for required care of exacerbations; or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids are required. A 100 percent rating requires an FEV-1 of less than 40 percent of the predicted value; or an FEV1/FVC ratio of less than 40 percent; or more than one attack per week of episodes of respiratory failure; or requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno- suppressive medications. 38 C.F.R. § 4.97, DC 6602. Evidence developed since entry of the final decision of August 16, 1996, fails to denote the existence of more than mild asthma prior to September 27, 2006, or pronounced asthma on and after September 27, 2006, in reference to the rating criteria in effect prior to October 1996. Moreover, findings from pulmonary function studies conducted on several occasions, including October 1997, June 1990, June 2000, December 2004, and September 2006, are inconsistent with the assignment of more than a 30 percent evaluation prior to September 27, 2006, or more than a 60 percent rating on and after September 27, 2006. It is noted that the ratio of FEV- 1 to FVC did not fall below 55 until the pulmonary function study of September 27, 2006, was completed, at which time the ratio was noted to be 54 percent. There is no indication that at least monthly visits to a physician were made for required care of asthmatic exacerbations or that intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids, or any more frequent use thereof, were required at any time during the period from October 1996 to the present. Likewise, more than one attack per week of episodes of respiratory failure is not indicated. Throughout the period in question, the preponderance of the evidence is against entitlement of the veteran to more than a 30 percent schedular evaluation for bronchial asthma prior to September 27, 2006, or more than a 60 percent rating therefor on or after September 27, 2006. Hart, supra. Inasmuch as a preponderance of the evidence is against the veteran's claim for increase, the benefit-of-the-doubt doctrine is not applicable, and the appeal must be denied. 38 U.S.C.A. § 5107(b); Gilbert; Ortiz, supra. The Board does not have the authority to assign, in the first instance, a higher rating on an extraschedular basis under 38 C.F.R. § 3.321(b)(1), and given the circumstances of this case, there is no basis to refer the matter to designated VA officials for consideration of an extraschedular rating. Bagwell v. Brown, 9 Vet. App. 377 (1996). Here the ratings assigned for the veteran's asthma take into account loss of time from work, as well as significant functional impairment. Such factors as a marked interference with employment or frequent periods of hospitalization are not corroborated by the evidence on file. Accordingly, a referral to the Chief Benefits Director or Director of the Compensation and Pension Service for a determination of whether the assignment of an extraschedular rating is appropriate is not warranted. Id. Claim for Increase: Postoperative Residuals of a Left Wrist Fracture Service connection for residuals of a left wrist fracture was established by RO action in April 1972. At that time, a 10 percent rating was assigned under DC 5299-5212, and that 10 percent rating has remained in effect since that time, although such disability is at present rated under DC 5215. DC 5215 provides for a 10 percent rating for limitation of motion of the wrist where dorsiflexion is less than 15 degrees or where palmar flexion is limited in line with forearm. 38 C.F.R. § 4.71a, DC 5215. The 10 percent evaluation under DC 5215 is the maximum assignable rating under that code, be it for the major or minor upper extremity. For VA purposes, normal dorsiflexion of the wrist is from 0 to 70 degrees, and normal palmar flexion is from 0 to 80 degrees. Normal ulnar deviation of the wrist is from 0 to 45 degrees, and normal radial deviation is from 0 to 20 degrees. 38 C.F.R. § 4.71, Plate I (2007). The DCs pertaining to impairment of the elbow, forearm, wrist, hand, and fingers apply different disability ratings based upon whether the major or minor arm is affected. 38 C.F.R. § 4.71a, DCs 5213 through 5230. Regardless of the criteria, when assigning a disability rating it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). Under 38 C.F.R. §§ 4.40 and 4.45, the rating for an orthopedic disorder must reflect functional limitation which is due to pain, as supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Notice is taken that the veteran is already in receipt of the highest schedular evaluation assignable under DC 5215 on the basis of limitation of motion of his left wrist. There is no foundation for the assignment of a separate evaluation due to arthritis of the left wrist, as the basis for rating arthritis is also limitation of motion. See VAOPGCPREC 9- 2004, 69 Fed. Reg. 59990 (2004); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998); VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997). The only other DC pertaining specifically to the wrist requires a showing of ankylosis in varying degrees, but there is no showing that the residuals of the veteran's left wrist fracture are manifested by ankylosis. There is otherwise no evidence indicating the existence of an impairment of the left radius, such that rating under DC 5212 would be for consideration. Because the veteran's left wrist disability is currently assigned the maximum disability rating available under 38 C.F.R. § 4.71a, DC 5215, the existence of objective evidence of pain or additional motion loss with repetitive motion does not warrant the assignment of an increased schedular evaluation under 38 C.F.R. §§ 4.40, 4.45 or DeLuca, given that pain or functional loss cannot be the basis for an award under a DC in excess of the maximum evaluation under that particular DC. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Further, in the absence of any evidence of record that the appellant's service-connected left wrist disorder causes "such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards," per 38 C.F.R. § 3.321(b)(1), a referral for consideration of an increased evaluation on an extraschedular basis is not warranted. See Bagwell v. Brown, 8 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 10 percent for the veteran's residuals of a fracture of the left wrist. Accordingly, the benefit-of- the-doubt doctrine is not applicable and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert; Ortiz, supra. ORDER Service connection for a genitourinary disorder, claimed as kidney disease and/or a disability manifested by hematuria, is denied. Service connection on a direct basis for a bilateral shoulder disorder is denied. Service connection on a direct basis for a low back disorder is denied. Service connection on a direct basis for depression and as secondary to service-connected bronchial asthma or postoperative residuals of a left wrist fracture is denied. A rating in excess of 30 percent for bronchial asthma prior to September 27, 2006, and in excess of 60 percent on and after September 27, 2006, is denied. An increased rating for postoperative residuals of a left wrist fracture, currently evaluated as 10 percent disabling, is denied. REMAND Further procedural and evidentiary development is found to be in order with respect to the veteran's claims for direct and secondary service connection for carpal tunnel syndrome (CTS) of the left upper extremity and for secondary service connection for bilateral shoulder and low back disorders. Regarding the veteran's claim for service connection for CTS of the left upper extremity, the record reflects that the veteran sustained a left wrist fracture in service, followed by a peg bone graft in that area, and that service connection was established therefor by RO action in April 1972. In connection with the instant appeal, the veteran has alleged that he has carpal tunnel syndrome of the left wrist and that it originated in the same fall that resulted in his left wrist fracture, or, alternatively, as a direct result of his service-connected left wrist fracture. Review of the record shows that there is conflicting evidence as to the existence of current disability, as briefly summarized by evidence now on file. Service medical records fail to identify any diagnosis of carpal tunnel syndrome of the left upper extremity and no diagnosis thereof is shown for many, many years following the veteran's discharge from service in March 1972. In August 1994, a clinical assessment of left hand weakness was recorded, and examination in July 1995 yielded the initial diagnosis of carpal tunnel syndrome affecting the left wrist and an opinion from an orthopedic physician that the cumulative effect of trauma throughout the years was its cause. (The veteran was on active duty for 4 years, from March 1968 to March 1972.) The orthopedist further noted that, among the records he had available for review, were reports in October and December 1992 indicating the existence of bilateral carpal tunnel syndrome, based on findings from nerve conduction velocity testing and an electromyogram. The veteran's ex-spouse has provided a statement, dated in May 1997. Therein, she noted that it was her recollection that the veteran had complained of left wrist pain during the 1970s and early 1980s. The record contains examination and treatment reports reflecting a clinical assessment in July 1997 of a history of bilateral CTS. At that time, the veteran was wearing a left wrist splint. Diagnoses of bilateral CTS were again noted in September and October 1997, despite nerve conduction and electromyogram findings then indicating no evidence of CTS of the left upper extremity. In August 1998, the veteran sustained a left wrist sprain when he tripped over a sidewalk, and in May 1999, a clinical impression was offered of possible left CTS versus C-6 cervical radiculopathy. On file is a medical record, dated in March 2003, which contains a diagnosis of bilateral, severe CTS. Reference was therein to the results of an electromyogram of March 2003 showing severe, bilateral median neuropathy and chronic denervation of the adductor pollicis muscle, bilaterally. Severe bilateral CTS was also diagnosed during the course of VA outpatient evaluation in September 2005. A VA medical examination was conducted in September 2006 to ascertain whether CTS of the left wrist was present and, if so, an opinion as to its etiology was to be furnished. Findings from that evaluation led the examiner to conclude that there was no basis for entry of a diagnosis of CTS of the left wrist or physical findings thereof. It was set forth by the examiner that the veteran reported that he had been treated for left wrist CTS since 1998 and that such treatment included use of self-prescribed wrist braces and over-the-counter pain medication. Specific reference to the March 2003 nerve conduction and electromyogram findings was not therein made. On the basis of the foregoing, further VA medical examination is deemed necessary in order to ascertain whether in fact there is now present current disability involving CTS of the veteran's left wrist. Moreover, if current disability is identified, then additional medical opinion is needed as to the question of whether existing service-connected disability of the veteran's left wrist has caused or aggravated CTS of the left upper extremity. 38 C.F.R. § 3.310; Allen, supra. As for the claims of secondary service connection for bilateral shoulder and low back disorders, previously provided opinions are found to be inadequate to permit the Board to consider fully the question of whether service- connected disability of the veteran's left wrist either caused or aggravated his right shoulder. Stegall, supra. Additionally, the RO has not to date been afforded the opportunity to adjudicate the claims for secondary service connection for CTS of the left upper extremity, or right shoulder and low back disabilities, on the basis of the amendment to 38 C.F.R. § 3.310, effective from October 2006. See 71 Fed. Reg. 52744 (2006). Accordingly, this portion of the appeal is REMANDED for the following actions: 1. Consistent with the provisions of 38 U.S.C.A. §§ 5103, 5103A (West 2002) and 38 C.F.R. § 3.159 (2007), the veteran must be provided notice of what additional information and evidence are needed to substantiate his claim for direct and secondary service connection for CTS of the left upper extremity and his claims for secondary service connection for right shoulder and low back disorders, secondary to service- connected disablement of the left wrist. The veteran must also be notified of what portion of that evidence VA will secure, and what portion he himself must submit and advised to submit all pertinent evidence not already on file that is held in his possession. Such notice must also include that pertinent to the holding in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The veteran must also be informed that, if requested, VA will assist him in obtaining updated records of treatment from private medical professionals, or other evidence, provided that he furnishes sufficient, identifying information and written authorization. The AMC/RO must also notify the veteran of a recent amendment to 38 C.F.R. § 3.310, effective October 10, 2006, which implemented the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice- connected disorder by service-connected disability. See 71 Fed. Reg. 52744 (2006). The amendment essentially codifies Allen with language that requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. Depending on the response received from the veteran, any and all assistance due him must then be afforded. 2. The RO/AMC should by separate correspondence advise the veteran of the need to obtain a copy of the report of nerve conduction velocity testing and an electromyogram of the left upper extremity conducted by a non-VA facility in March 2003. Authorization to permit VA to obtain such report(s) should be requested, and once received, the AMC or RO should contact the non-VA facility in order to obtain such report(s) for inclusion in the claims folder. 3. All records of VA medical treatment, not already on file, which pertain to the veteran's claimed CTS of the left upper extremity, right shoulder disorder, and low back disorder should be obtained and made a part of his claims folder. 4. Thereafter, the veteran must be afforded VA orthopedic and neurological examinations in order to determine the nature and etiology of claimed disorders involving CTS of the left upper extremity, his right shoulder, and the low back. The claims folder should be provided to each examiner for use in the study of this case and their report(s) should indicate whether the claims folder was in fact made available and reviewed. Each examination should include a detailed review of the veteran's history and current complaints, as well as a comprehensive clinical evaluation and any and all diagnostic testing deemed necessary. All applicable diagnoses must be specified and it must be noted whether there is present or absent CTS of the left upper extremity. If and only if there is a current diagnosis of CTS of the left upper extremity, then the examining neurologist is asked to furnish a professional medical opinion and supporting rationale as to the following question: Is it at least as likely as not (50 percent or greater probability) that the veteran's postoperative residuals of a left wrist fracture caused or aggravated his CTS of the left upper extremity? The orthopedic examiner is asked to furnish a professional medical opinion and supporting rationale as to the following questions: (a) Is it at least as likely as not (50 percent or greater probability) that the veteran's postoperative residuals of a left wrist fracture caused or aggravated any existing disorder of his right shoulder? (b) Is it at least as likely as not (50 percent or greater probability) that the veteran's postoperative residuals of a left wrist fracture caused or aggravated any existing disorder of his low back? Each examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship or a finding of aggravation; less likely weighs against the claim. Each examiner is also informed that aggravation for legal purposes is defined as a chronic worsening of the underlying disability versus a temporary flare up of symptoms. It represents a permanent increase in severity, beyond its natural progression. Each examiner is requested to provide a rationale for any opinion provided, preferably with citation to the clinical record. If the examiner determines that the claimed aggravation occurred, to the extent that is possible, he or she should provide the approximate degree of severity of the aggravated disability (the baseline level of functional impairment) before the onset of aggravation (e.g., slight then, moderate now). If either examiner is unable to answer any question presented without resort to speculation, he or she should so indicate. 5. Lastly, the veteran's claim of entitlement to direct and secondary service connection for CTS of the left upper extremity and his claims for entitlement to secondary service connection for right shoulder and low back disorders, due to service-connected disablement of the left wrist, should readjudicated on the basis of all relevant evidence and all governing legal authority, to include the October 2006 change to 38 C.F.R. § 3.310. If any benefit sought on appeal is not granted, he and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. The veteran need take no action until he is notified. He has the right to submit additional evidence and argument on the matter(s) the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of this remand is to obtain additional evidentiary and procedural development. No inference as to the outcome of this matter should be drawn from the actions requested. ______________________________________________ R. F. WILLIAMS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs