Citation Nr: 0811136 Decision Date: 04/04/08 Archive Date: 04/14/08 DOCKET NO. 04-40 607 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to service connection for paroxysmal supraventricular tachycardia, to include as secondary to post-traumatic stress disorder. 3. Entitlement to a rating in excess of 10 percent for low back strain and anomalous lumbosacral joint. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Douglas J. Boorstein, Associate Counsel INTRODUCTION The veteran had active service in the United States Air Force from February 1968 to January 1974. The veteran also had service in the Air Force Reserves. These matters come before the Board of Veterans' Appeals (Board) on appeal of a July 2003 rating decision of the Tiger Team at the Department of Veterans Affairs (VA) Regional Office (RO) located in Cleveland, Ohio. Thereafter, the veteran's claims file was returned to his local RO in Honolulu, Hawaii. Although the veteran initially requested a hearing before the Board, he withdrew this request by correspondence dated June 2005. Thus, no additional action in this regard is needed. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been received. 2. The veteran does not have a diagnosis of post-traumatic stress disorder. 3. The competent and credible evidence does not create a nexus between the veteran's paroxysmal supraventricular tachycardia and active service or any service-connected disability. 4. The veteran's low back strain with anomalous lumbosacral joint is productive of characteristic pain on motion and forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. It is not productive of 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 is not greater than 120 degrees; nor is there muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The veteran does not have forward flexion of the thoracolumbar spine to 30 degrees or less or favorable or unfavorable ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. Post-traumatic stress disorder was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007). 2. The veteran's paroxysmal supraventricular tachycardia was not incurred in or aggravated by service, nor is it proximately due to or the result of any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 3. The criteria for the assignment of a rating in excess of 10 percent for low back strain with anomalous lumbosacral joint have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5292, 5293, 5295 (2002); 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003); 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5243 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Legal Criteria The veteran contends that he has PTSD as a result of his military service. He also contends that he has paroxysmal supraventricular tachycardia as a result of his PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. Service connection for a cardiovascular condition may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 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) (2007). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the veteran had a chronic condition in service or during an applicable presumption period and still has such a condition. Such evidence must be medical unless it relates to a condition as to which, under the United States Court of Appeals for Veteran's Claims' (Court's) case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). In addition, if a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2007). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement 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. In sum, establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Heuer v. Brown, 7 Vet. App. 379, 384 (1995). Secondary service connection is awarded when a disability "is proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310 (2007). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310. Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Regarding the veteran's claim for service connection for PTSD, the Board additionally observes that service connection for this condition in particular requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) [i.e., a diagnosis under DSM-IV]; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). The Board reiterates that Congress specifically limits entitlement for service- connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. § 1110. In the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). PTSD In this case, the veteran's stressors include both racial discrimination on active duty and stressors related to combat. Regarding the combat stressors, the record reflects that the veteran was assigned to both Cam Rahn Bay Airbase and Phan Rang Airbase in Vietnam, and the veteran contends that his combat-related stressors took place in and around these airbases, between December 1969 and January 1971. The veteran indicates that he saw four or five Viet Cong bodies displayed next to the road while crossing a bridge and he described an encounter where a thirteen-year-old boy threatened him with a gun and indicated that he should leave the area. The veteran has also contended that non-combat related racially motivated stressors took place after this time period. After a careful review of the probative and persuasive evidence of record, the Board finds that the veteran does not have PTSD. The veteran's alleged in-service stressors are acknowledged. Nonetheless, his service personnel and medical records do not indicate any psychological difficulties. In fact, on separation examination in December 1973, the veteran was noted to be psychiatrically normal and on his report of medical history, he denied nervous trouble of any sort. Regarding the veteran's post service medical evidence, the Board notes that in January 1999, a VA social worker, C.L., indicates that the veteran has a diagnosis of PTSD. C.L. indicated that as the veteran's combat experience was rather "light," she believed that the PTSD might be associated with anti-Asian sentiments that he was exposed to when he was in the military. The VA social worker described various incidents in which the veteran was exposed to what he believed were racially-motivated actions, including being reprimanded by a supervisor and being reassigned to a different Air Force Base. There is no indication that the VA social worker had access to the veteran's claims file. In a March 2001 letter, F.M. a private psychologist, indicates that the veteran met the diagnosis for PTSD. The psychologist indicated that the duration of the symptoms extended back to the Vietnam War. There is no indication that the psychologist had access to the veteran's claims file. It is also noted that in an August 2002 Mental Health Services Department Progress Note, M.E., indicates that the veteran has major depression, but does not diagnose PTSD, and R.B., a VA social worker and employee of the Honolulu Vet Center, indicates that the veteran has "anxiety problems," but does not indicate that the veteran has PTSD. In addition to the foregoing, and most importantly, a VA examination performed in August 2007 indicates that the veteran does not have a diagnosis of PTSD. The record indicates that the veteran described the stressors that he experienced to the examiner, including both the racially- related stressors as well as the non-racially related stressors. The examiner concluded that while the patient does have experiences in the military in which he felt helplessness and horror due to discrimination, it was not clear whether the veteran experienced actual or threatened death or serious bodily injury, or a threat to physical integrity of self or others. The examiner therefore concluded that the veteran did not meet the criteria for a diagnosis of PTSD. Although there are medical reports or record noting a diagnosis of PTSD, the Board finds that those diagnoses are of little or no probative value. In Wood v. Derwinski, 1 Vet. App. 406 (1991) the Court held that the Board is not bound to accept the diagnosis of PTSD if the evidence of record does not objectively support that diagnosis. In this regard, the Board notes that none of the individuals who diagnosed PTSD had access to the veteran's claims file. The Board also points out that two of the veteran's treating physicians' have not indicated that the veteran has PTSD. Further, on VA examination in 2007, the examiner, after reviewing the veteran's claims file, reported history, and examining him determined that the veteran did not have PTSD. The examiner then supported his conclusion with a thorough and well-reasoned analysis. Given the aforementioned, the Board accords this examination great probative weight and rejects the other opinions of record. As such, the Board finds that the veteran does not have PTSD. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Court stated "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability," and held "[i]n the absence of proof of a present disability[,] there can be no valid claim"); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). As previously noted, the Board acknowledges the veteran's alleged in-service stressors and notes that the veteran has submitted various articles pertaining to difficulties that Asian-Americans have incurred in the military, including PTSD. Nonetheless, the veteran's assertions and treatise evidence fail to demonstrate a current diagnosis of PTSD. In addition, it is noted that an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive. Mattern v. West, 12 Vet. App. 222, 227 (1999). Also, while the veteran appears sincere in his belief that he has PTSD, he is not competent to diagnose himself with a psychological condition and attribute it to service. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board therefore finds that the preponderance of the competent and credible evidence is against the claim of entitlement to service connection for post-traumatic stress disorder, and there is no doubt to be resolved. See Gilbert, 1 Vet. App. at 55. Paroxysmal Supraventricular Tachycardia The veteran contends that he has paroxysmal supraventricular tachycardia as a result of his service in Vietnam and/or PTSD. At the outset, the Board notes that a current diagnosis of paroxysmal supraventricular tachycardia is of record. However, the requirements for service connection still are not met. There is no evidence to indicate that the veteran had this disability while in service and there is no probative evidence attributing the veteran's paroxysmal supraventricular tachycardia to service. Service medical records do not indicate that the veteran experienced any problems with his heart while in service. On separation in December 1973, the veteran's heart was noted as normal. The veteran denied any palpitations, pounding heart sensations and heart trouble. The record thereafter is silent for any complaints of or findings associated with paroxysmal supraventricular tachycardia until 2002. This is over twenty years after service and is well outside the one-year presumptive period established for cardiovascular disease. In addition, there is no competent medical evidence of record creating a nexus between the veteran's current disability and service. The record shows that the veteran's disability did not begin in service, manifest to a compensable degree within a year of service, and is not in any way related to any event of service. The veteran also contends that his paroxysmal supraventricular tachycardia is a result of the PTSD he incurred in service. As determined above, service connection for PTSD is not in effect; thus, as a matter of law, it follows that service connection cannot be granted for the veteran's paroxysmal supraventricular tachycardia as a result of his PTSD. 38 C.F.R. § 3.310. The evidence weighs against the veteran's claim of entitlement to service connection for his paroxysmal supraventricular tachycardia. Accordingly, the veteran's claim must be denied, and there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Rating Low Back Strain with Anomalous Lumbosacral Joint Law and Regulations Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. In cases where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. The RO received the veteran's claim in October 2000. During the course of this appeal the regulations for rating disabilities of the spine were revised effective September 23, 2002, and effective September 26, 2003. See 67 Fed. Reg. 54345 (Aug. 22, 2002), 68 Fed. Reg. 51454 (Aug. 27, 2003). Prior to September 23, 2002, the Rating Schedule provided evaluations for limitation of motion of the lumbar spine when limitation was slight (10 percent), moderate (20 percent), or severe (40 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5292 (effective before September 23, 2002). Prior to September 23, 2002, the Rating Schedule provided ratings for lumbosacral strain when the disorder is shown to be slight with subjective symptoms only (0 percent), with characteristic pain on motion (10 percent), with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position (20 percent), and with a severe disability manifested by listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, and narrowing or irregularity of the joint space (40 percent). A 40 percent evaluation was also warranted if only some of these manifestations are present if there was also abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (effective before and after September 23, 2002). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). VA regulations require that a finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40. Functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589 (1993). Under the former provisions of Diagnostic Code 5293, a noncompensable evaluation is assigned for postoperative, cured intervertebral disc disease, a 10 percent evaluation is assigned for mild intervertebral disc disease, a 20 percent rating is assigned for intervertebral disc syndrome which is moderate with recurring attacks, a 40 percent rating is warranted for intervertebral disc syndrome that is severely disabling with recurring attacks and intermittent relief, and a 60 percent evaluation is assigned for intervertebral disc disease which is pronounced with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of diseased disc, little intermittent relief. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (in effect prior to September 23, 2002). Under the interim revised criteria of Diagnostic Code 5293, effective September 23, 2002, intervertebral disc syndrome is evaluated (preoperatively or postoperatively) either on the total duration of incapacitating episodes over the past 12 months, or by combining under 38 C.F.R. § 4.26 (combined rating tables) separate evaluations of chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, which ever method results in the higher evaluation. A maximum 60 percent rating is warranted when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than 6 weeks, during the past 12 months. A 20 percent rating is assigned for incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months, and a 10 percent rating is assigned with the incapacitating episodes having a total duration of at least one week, but less than two weeks, during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is 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 neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note 2 provides that when evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurological disabilities separately using evaluation criteria for the post appropriate neurological diagnostic code or codes. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (September 23, 2002). Under the new criteria of Diagnostic Code 5237 and 5243, effective September 26, 2003, with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the 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 an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted 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. A 40 percent rating is warranted for forward flexion of the thoracolumbar to 30 degrees or less, or when there is favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating, and unfavorable ankylosis of the entire spine warrants a 100 percent rating. There are several notes set out after the diagnostic criteria, a summary of which is as follows. First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion of 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 140 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. Under the new criteria, intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the general rating for disease and injuries of the spine (outlined above) 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 38 C.F.R. § 4.25. The formula for rating intervertebral disc syndrome based on incapacitating episodes remains the same as the interim revised criteria. Only the code assignment has changed. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (effective September 26, 2003). When a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-03; 69 Fed. Reg. 25179 (2003). The amended versions may only be applied as of their effective date and, before that time, only the former version of the regulation may be applied. VAOPGCPREC 3-00; 65 Fed. Reg. 33422 (2000); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Consequently, the Board has considered whether an increased evaluation may be warranted under either the old or new version of the schedule for rating disabilities of the spine. The Board recognizes, however, that application of the newer regulations can be no earlier than the effective date of the change. Analysis After reviewing the pertinent evidence of record along with applicable law and regulations, the Board finds that an increased rating is not warranted. The veteran's lumbosacral strain with anomalous lumbosacral joint was initially rated under the "old" Diagnostic Code 5295 (lumbosacral strain) and is now being rated based on the "new" Diagnostic Code 5237 (limitation of motion). With regard to the veteran's limitation of motion, the Board notes that under either Diagnostic Code 5292 or 5237, the veteran's limitation of motion of the lumbar spine warrants no more than a 10 percent rating. Under the "old" criteria, his disability is best described as slight, warranting a 10 percent rating. Under the "new" criteria, the veteran's flexion ranges between 80 degrees and 95 degrees, and there is no evidence of muscle spasm, guarding severe enough to result in an abnormal gait, abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, or anklyosis. See VA examination reports dated in September 2002 and August 2007. Thus, no more than a 10 percent rating is warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2002), Diagnostic Code 5237 (2007). In addition to the foregoing, even when considering the mandates of DeLuca, the veteran has always had at least 80 degrees of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5292. Further, there is no evidence of increased impairment due to weakness, fatigability, incoordination, or pain on movement so as to warrant the assignment of a higher rating. The assignment of a higher rating is not warranted under the "old" Diagnostic Code 5295 either. In this case, under the prior criteria, the veteran's disability was described as having "characteristic pain on motion." The record also shows that there is no evidence of muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. Nor is there a severe lumbosacral strain manifested by listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, and narrowing or irregularity of the joint space or any abnormal mobility on forced motion. Clinical findings recorded on VA examinations in September 2002 and August 2007 do not indicate muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in the standing position. The veteran only has characteristic pain on motion. Neither examiner noted abnormal spine curvatures, including gibbus, kyphosis, list, lumbar flattening, lumbar lordosis, scoliosis, or reverse lordosis. There was no evidence of spasm, atrophy, guarding, pain with motion, tenderness, or weakness. Finally, a higher rating under Diagnostic Code 5293 or Diagnostic Code 5243 (pertaining to intervertebral disc disease) is not warranted either. The veteran's disability is not productive of moderate, severe, or pronounced intervertebral disc syndrome, nor is it productive of any incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months or incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Thus, a higher rating under these provisions is not warranted. The Board has also considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran as well as the entire history of the veteran's disabilities in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A separate rating is not warranted in this regard either. Under the "new" criteria, separate evaluations can be assigned for associated objective neurological abnormalities under other diagnostic codes. However, in this case, the record is void of any separately compensable associated bowel, bladder, erectile dysfunction or any other neurological abnormalities associated with the veteran's service-connected low back strain and anomalous lumbosacral joint disability. Based on a complete review of the record, the Board finds that during the entire rating period on appeal, the veteran's symptoms associated with his low back strain and anomalous lumbosacral joint have more nearly approximated the criteria for a 10 percent rating and no more. Hart v. Mansfield, 21 Vet. App. 505 (2007). It is also noted that the veteran has not indicated that his income has declined substantially as a result of his service- connected low back strain and anomalous lumbosacral joint. Further, there is no evidence (nor has the veteran contended) that his disability necessitates frequent periods of hospitalization, such that application of the regular schedular standards is rendered impracticable. The referral for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) (2007) is not warranted. In summary, the preponderance of the evidence is against the veteran's claim, and the benefit of the doubt doctrine is not for application. The claim is denied. Gilbert, 1 Vet. App. at 54. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (2006); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and that (4) VA will request that the claimant provide any evidence in his possession that pertains to the claim. The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). The Board concludes that the veteran has been afforded proper notice under the VCAA. The RO provided a VCAA notice letter to the veteran in February 2001 and September 2002. The veteran's claims have been readjudicated multiple times. Prickett v. Nicholson, 20 Vet. App. 370 (2006). The VCAA letters notified the veteran that VA would obtain federal records on his behalf and that he should assist in obtaining private medical records. It did not, however, specifically explain the elements set forth in Pelegrini. Here, the duty to notify, therefore, was not satisfied prior to the initial unfavorable decision on the claim by the agency of original jurisdiction (AOJ). Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial AOJ decision by way of a letter sent to the appellant in March 2006 that fully addressed all four notice elements. The letter informed the appellant of what evidence was required to substantiate the claim and of the appellant's and VA's respective duties for obtaining evidence. The appellant was also asked to submit evidence and/or information in his possession to the AOJ. Although the notice letter was not sent before the initial AOJ decision in this matter, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case by way of a rating decision dated September 2007, after the notice was provided. The veteran indicated, by form submitted in October 2007, that he had no additional evidence to submit. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. To whatever extent the decision of the Court in Dingess v. Nicholson, supra, requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the veteran in proceeding with the present decision. Although the veteran was not initially notified of these elements, the veteran was subsequently informed of this information in March 2006. The veteran's case was then readjudicated in September 2007. For similar reasons to those discussed above, the veteran has not been prejudiced. See Prickett. For an increased-compensation claim, section 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. January 30, 2008). Further, if the Diagnostic Code 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 Diagnostic Codes, 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. Here, the VCAA duty to notify has not been satisfied with respect to the requirements set forth by Vazquez-Flores. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent with the purposes of both the VCAA and VA's uniquely pro-claimant benefits system. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show 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 v. Peake, No. 05-0355, slip op. at 12 (U.S. Vet. App. January 30, 2008) ("Actual 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 v. Peake, No. 05-0355, slip op. at 9 (U.S. Vet. App. January 30, 2008). In this case, the Board finds that the notice error did not affect the essential fairness of the adjudication because the veteran has shown actual knowledge of the requirements. The veteran has submitted numerous medical records pertaining to his conditions, including his back conditions. The veteran has therefore shown that he has actual knowledge of the fact that medical evidence would assist in substantiating his appeal. Thus, the veteran has not been prejudiced. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has received the veteran's service medical records, VA treatment records, and private medical records. The record indicates that the veteran receives treatment at a Vet Center in Honolulu, Hawaii. The records pertaining to that treatment have not been obtained. However, the veteran has submitted a statement, discussed above, from his provider. The Board has considered this statement in its decision. The statement indicated that the veteran was receiving treatment for anxiety disorder, and did not indicate that he was receiving treatment for PTSD. Additional action in this regard is not warranted. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant). Although the veteran has provided information regarding stressors, additional action is not required in this regard. The claim for service connection for post-traumatic stress disorder is denied due to the absence of a current PTSD diagnosis. VA will discontinue providing assistance in obtaining evidence for a claim if the evidence obtained indicates that there is no reasonable possibility that further assistance would substantiate the claim. 38 C.F.R. § 3.159(d). Assistance to the veteran shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Regarding the veteran's claimed PTSD and his claimed paroxysmal supraventricular tachycardia, an examination was obtained in August 2007. Regarding the veteran's claimed back disability, VA examinations were obtained in September 2002 and August 2007. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. Therefore, no further assistance to the veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) ORDER Entitlement to service connection for post-traumatic stress disorder is denied. Entitlement to service connection for paroxysmal supraventricular tachycardia, to include as secondary to post-traumatic stress disorder is denied. Entitlement to a rating in excess of 10 percent for low back strain and anomalous lumbosacral joint is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs