Citation Nr: 0812233 Decision Date: 04/14/08 Archive Date: 05/01/08 DOCKET NO. 05-28 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent prior to September 26, 2003, a rating in excess of 20 percent from September 26, 2003, to January 23, 2006, and a rating in excess of 30 percent, effective January 23, 2006, for a cervical spine disability. 2. Entitlement to a total disability rating for individual unemployment (TDIU) prior to January 23, 2006. 3. Entitlement to service connection for Reiter's Syndrome. 4. Entitlement to service connection for a right hand disorder, to include as secondary to Reiter's Syndrome. 5. Entitlement to service connection for a left hand disorder, to include as secondary to Reiter's Syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD N. Snyder, Associate Counsel INTRODUCTION The veteran had active service from November 1979 to May 1993, with two years prior active service. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions by the Department of Veterans Affairs (VA) St. Petersburg, Florida, Regional Office (RO). The issues of service connection for Reiter's Syndrome and bilateral hand disorders are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to February 2, 2005, the veteran's cervical spine disability is manifested by moderate limitation of motion, without "incapacitating episodes," severe intervertebral disc syndrome, ankylosis, or objective neurological abnormalities. 2. Effective February 2, 2005, the veteran's cervical spine disability is manifested by severe limitation of motion, but no ankylosis, severe intervertebral disc syndrome, "incapacitating episodes," or objective neurological abnormalities. 3. Prior to February 2, 2005, the veteran has a combined rating of less than 70 percent, and the evidence does not indicate that service-connected disabilities rendered the veteran unfit for gainful employment. 4. Effective February 2, 2005, the veteran had a combined rating of 70 percent and, the evidence suggests that the service-connected disabilities are of such nature and severity as to prevent him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to February 2, 2005, the criteria for a 20 percent rating, but no higher, and effective February 2, 2005, the criteria for a 30 percent rating, but no higher, for the cervical spine disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5290, 5293 5235 to 5243 (2002, 2003, 2007); DeLuca v. Brown, 8 Vet. App. 202 (1995). 2. From February 2, 2005, forward, the criteria for TDIU have been met, but prior to February 2, 2005, the criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.16 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). 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, 22 Vet. App. 37 (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. In September 2004, the agency of original jurisdiction (AOJ) sent a letter to the veteran providing notice of what the evidence needed to demonstrate, of his and VA's respective duties in obtaining evidence, and of the types of relevant evidence that he should provide, or ask the VA to obtain for his claims of increased rating and TDIU. Although the September 2004 notice letter postdated the initial adjudication, no prejudice resulted as the claims were subsequently readjudicated. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). The Board notes that notice regarding effective dates was attached to a May 2006 SSOC. Any error in timeliness of this notice is harmless error, as further delaying the resolution of the claims adjudicated herein it is outweighed by the benefits granted by this decision. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), The specific rating criteria for evaluating the cervical spine disability and how (based on what symptomatology) each rating percentage is assigned were provided to the veteran in the August 2005 Statement of the Case. Although the veteran was not sent an independent letter providing notice of this information, the records indicates that no prejudice resulted. The claim was readjudicated after this notice was provided, the veteran was able to effectively participate extensively in the appeals process, and the veteran had ample time to submit evidence. The evidence indicates that the veteran was fully aware of what was necessary to substantiate this claim. VA has also done everything reasonably possible to assist the veteran with respect to the claims of increased rating and TDIU, such as obtaining medical records, providing a personal hearing, and providing VA examinations. Consequently, the Board finds that the duty to notify and assist has been satisfied. Cervical Spine Disability For historical purposes, it is noted that service connection was established for residuals of traumatic injury to cervical spine with left shoulder pain and weakness by the RO in a November 1994 decision, based on evidence of in-service injury and treatment for radicular left shoulder pain, and a 10 percent disability evaluation was assigned based on a review of the relevant contemporaneous evidence of record. The service connected disability was later recharacterized as residuals of traumatic injury to cervical spine with disc narrowing C4-C5 based on competent medical findings that the bilateral arm weakness and shoulder pain were not related to the cervical spine disability. See, e.g., June 1998 Tannenbaum record; March 2005 VA examination record. The Board notes that the RO also has denied service connection for bilateral hand numbness and pain secondary to the cervical spine disability; consequently, the symptomatology associated with the bilateral hand disorder will not be discussed in this decision. In September 1999, the veteran filed a claim for a rating in excess of 10 percent for his cervical spine disability. Effective September 23, 2003, the RO increased the rating for the veteran's cervical spine disability to 20 percent, and effective January 23, 2006, the RO increased the rating to 30 percent. During the pendency of this appeal, the rating criteria for evaluating intervertebral disc syndrome (IDS) were amended (effective September 23, 2002) and the criteria for evaluating general diseases and injuries of the spine were amended (effective September 26, 2003). The Board is required to consider the claim in light of both the former and revised schedular rating criteria to determine whether an increased evaluation for the veteran's degenerative disc disease of the cervical spine is warranted. VA's Office of General Counsel (OGC) has determined that the amended rating criteria, if favorable to the claim, can be applied only for periods from and after the effective date of the regulatory change. See VAOPGCPREC 3-2000. What remains unclear, however, is whether the "old" criteria can be applied prospectively, although the OGC, in VAOPGCPREC 7-2003 seems to indicate (this opinion is not entirely clear) that VA is no longer obligated to apply superseded rating schedule provisions prospectively for the period subsequent to the issuance of the revised rating criteria. In any event, and given the confusing nature of this opinion, the Board, in giving the veteran all due consideration, will apply the old criteria prospectively. A March 2000 VA examination record reports the veteran's history of intermittent posterior cervical pain with frequent radiation to the left shoulder. The examiner noted that there was mild diffuse tenderness of the cervical spine with no crepitus or paraspinal spasm. Range of motion showed forward flexion to 25 degrees, extension to 25 degrees, bilateral lateral flexion to 40 degrees, and bilateral rotation to 50 degrees. There was no objective evidence of pain on motion. Neurological testing, including sensation, motor function, and deep tendon reflexes, was normal. The veteran was diagnosed with chronic strain of the cervical spine. A February 2001 VA spine examination reports the veteran's history of severe neck pain that radiated down the left arm and across the left chest. Range of motion was 30 degrees flexion, 20 degrees extension, 30 degrees lateral flexion bilaterally, and 30 degrees bilateral rotation. There was grinding on rotation, and the examiner noted that the veteran complained of pain at the base of the neck when he went "through these maneuvers." A February 2001 VA peripheral nerves examination record reports that sternocleidomastoid and trapezius were strong and equal; the extremities had 5/5 strength throughout; there was no genuine weakness of the hands on examination; sensations were normal throughout; and reflexes were 2+ and equal. There was a "give-way weakness." The examiner diagnosed the veteran with degenerative disc disease, though the Board notes that the diagnosis was solely based on the veteran's history of a past diagnosis. (The record notes that the claims file was not available, and no tests were ordered). An August 2002 VA treatment record reports that the veteran had no arm weakness or numbness, and he had 4/5 strength in the biceps, deltoid, and hand grip. The record notes that the veteran was neurologically intact. A March 2004 VA examination record notes the veteran's history of constant pain that was aggravated by movement and that radiated down the left shoulder and arm to the fingers. The veteran also reported having constant stiffness and "more severe pain approximately [two] times weekly" which last approximately two hours per episode and which require him to sit down and rest. There was no incapacitation. Physical examination revealed no spasm, paravertebral tenderness, or sensory loss to pinprick or fine touch. Range of motion testing indicated that the veteran had flexion to 30 degrees, extension to 20 degrees, right rotation to 50 degrees, left rotation to 30 degrees, and lateral flexion to 15 degrees bilaterally. The veteran reported pain with all range of motion. There was no additional loss of range of motion due to pain, weakness, fatigue, or lack of endurance after repetitive use. The examiner noted that upper extremity strength was difficult to evaluate because the veteran would not comply secondary to pain in the neck. The veteran was diagnosed with chronic cervical pain, and the examiner opined that the veteran's bilateral shoulder pain was not related to his cervical spine condition. A February 2, 2005, private computerized spinal range of motion examination record reports that flexion was to 19 degrees, extension to 4 degrees, left lateral flexion to 10 degrees, right lateral flexion to 6 degrees, right rotation to 19 degrees, and left rotation to 11 degrees. An April 2005 private magnetic resonance imaging (MRI) record reports impressions of straightened cervical lordosis suggesting muscle spasm or sprain, disc bulges, central disc protrusion at C5-6, and left foraminal narrowing. A January 2006 VA examination record reports the veteran's history of chronic neck stiffness and pain, and he reported that the pain radiated down both arms, worse in the left arm. The veteran denied having flare-ups. The examiner stated that the veteran did not have incapacitating episodes. Physical examination indicated tenderness in the cervical spine area, and range of motion was reported as forward flexion to 10 degrees, extension to 10 degrees, lateral flexion to 15 degrees bilaterally, and rotation to 25 degrees bilaterally. The examiner noted that the veteran had pain at the final degree with no additional loss of motion after repetition due to pain, fatigue, weakness, or lack of endurance. Neurological evaluation indicated the veteran's history of decreased sensation to touch and pinprick in the upper extremities bilaterally. There were no other focal neurological abnormalities or muscle atrophy. The veteran was assessed with residuals of traumatic injury to the cervical spine with disc narrowing C4-C5 with degenerative disc disease. The examiner also reported that the veteran's complaints of radiating pain were as likely as not secondary to radiculopathy from the cervical spine disability. In January 2006, the veteran testified at a personal hearing on the current severity of his cervical spine disability. The veteran testified that he is "totally [incapacitated] four to five days out of a week." He stated that he cannot do anything except sit on a couch; walking, getting up, and lifting are "absolutely excruciating." He estimated that he was incapacitated approximately 26 days a month. He reported that he received a cortisone shot during the period, but otherwise, the veteran did not report any doctor's treatments during these "episodes". An October 2006 VA treatment record reports the veteran's history of neck pain, estimated as 3/10 to 5/10, with stiffness. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 38 C.F.R. § 4.14. While the veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection 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. Francisco v. Brown, 7 Vet. App. 55 (1994). A relatively recent decision of the Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The "old" rating criteria for the spine provided a 20 percent rating for "moderate" limitation of motion and a 30 percent rating for "severe" limitation of motion. When determining the proper rating percentage under DC 5290, functional loss due to flare-ups, fatigability, incoordination, weakness, and pain on movements must be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995); 38 C.F.R. § 4.40. 38 C.F.R. § 4.45. Based on the range of motion findings reported in the March 2000 and February 2001 VA examinations (and the current regulations' interpretation of "normal" range of motion as 45 degrees extension, forward flexion, and unilateral flexion and 80 degrees unilateral rotation) and the February 2001 examiner's finding that there was pain on motion, the Board finds that the veteran's cervical spine disability warrants a 20 percent rating under DC 5290 prior to September 26, 2003. Additionally, based on the objective evidence of more severe symptoms reported by the February 2005 record, the Board finds that a 30 percent rating, but no higher, is warranted effective February 2, 2005, the date of the private treatment record. Effective February 2, 2005 Effective February 2, 2005, the Board finds that a 30 percent rating is warranted for the veteran's cervical spine disability under DC 5290 for "severe" limitation of motion based on the range of motion reported by the February 2005 private treatment record. The Board finds that the evidence does not warrant a rating in excess of 30 percent, however. The "new" and "old" regulations provide ratings in excess of 30 percent for unfavorable ankylosis of the entire cervical spine. See 38 C.F.R. § 4.71a Diagnostic Code 5287, 5237 (2002 and 2007, respectively). The medical evidence does not include any findings of ankylosis; consequently, a higher rating is not warranted under these diagnostic codes. An increased rating is not available by combining separate ratings for limitation of motion and objective neurological abnormalities under the "new" General Rating Formula of the Spine. See Note (1). Although the evidence indicates findings of radiculopathy and diminished sensation, the evidence does not indicate that the veteran has associated objective neurological abnormalities, such as bladder impairment, motor loss, or a reflex deficit which would warrant a compensable, separate rating. Id. Finally, a higher rating is not available by rating the cervical spine disability under the rating criteria for IDS. The "new" IDS rating criteria provide a 40 percent rating for IDS with incapacitating episodes, defined as an episode requiring physician-prescribed bed rest and medical treatment, having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. See 38 C.F.R. § 4.71a, DC 5293 (2002); 38 C.F.R. § 4.71a, DC 5243 (2007). Although the veteran testified that he is incapacitated approximately 26 days a month, the record includes no medical certificates of doctor-prescribed bedrest. Additionally, the evidence, to include the veteran's testimony, does not indicate that the veteran has received treatment during the reported incapacitations. Consequently, a higher rating is not warranted under the "new" criteria for IDS. The "old" DC 5293 provides a 40 percent rating for severe IDS with recurring attacks with intermittent relief. Although the veteran's testimony indicates his opinion that his cervical spine disability results in little intermittent relief and the evidence includes findings of possible muscle spasm and radiculopathy, the competent medical evidence does not indicate that the veteran's IDS symptomatology approximates "severe" IDS. The evidence indicates that the veteran had no muscle atrophy and no focal neurological abnormalities other than decreased sensation, and examinations indicate negative findings as to demonstrable spasm. Additionally, the contemporaneous treatment records, such as the October 2006 VA treatment record, do not corroborate the veteran's testimony that he is "incapacitated" 26 days out of a month. Based on the foregoing medical findings, the Board finds that the evidence does not approximate "severe" IDS. Prior to February 2, 2005 The evidence of record prior to February 2, 2005, warrants a 20 percent rating, but no higher, for limitation of motion. As stated above, the "old" DC 5290 provides a higher rating for "severe" limitation of motion. Although the evidence includes findings that range of motion is limited by pain, the veteran's range of motion is sufficiently significant, even after consideration of pain, as to more nearly approximate "moderate" limitation of motion rating, rather than "severe" limitation of motion rating. Consequently, a higher rating is not warranted under the "old" DC 5290. A higher rating is also not warranted under the "old" DC 5287 as the record reports no findings of ankylosis. Additionally, a higher rating is not warranted under the "new" rating criteria for the spine, which provides ratings in excess of 20 percent for limitation of forward flexion of the cervical spine to less than 15 degrees or ankylosis. The veteran is not entitled to an increased rating under the new general rating formula (DC 5237) as he can flex his cervical spine beyond 15 degrees (even when considering pain) and is not noted to have ankylosis. An increased rating is also not available by combining separate ratings for limitation of motion and objective neurological abnormalities, as provided by the General Rating Formula of the Spine, Note (1). The treatment records do not report any definite, objective findings of radiculopathy (only "history of cervical radiculopathy"); neurological exams were normal in March 2000, February 2001, and August 2002; and the March 2004 examination record reports that the veteran had no sensory loss or spasm. The records report no medical diagnosis of any objective neurological abnormality associated with the cervical spine disability which may be separately evaluated so as to increase the overall evaluation of the veteran's service-connected cervical spine disorder. Finally, a higher rating is also not warranted by rating the veteran under the "old" or "new" rating criteria for intervertebral disc syndrome (IDS). The "old" (pre- September 23, 2002) IDS rating criteria provide a 40 percent rating for "severe" IDS with recurring attacks and intermittent relief. The "new" IDS rating criteria provide a 40 percent rating for IDS with incapacitating episodes, defined as an episode requiring physician-prescribed bed rest, having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. See 38 C.F.R. § 4.71a, DC 5293 (2002); 38 C.F.R. § 4.71a, DC 5243 (2007). Initially the Board notes that a higher rating is not warranted under the "new" IDS rating criteria as the evidence includes no evidence or history of "incapacitating episodes." A higher rating is also not warranted under the "old" IDS rating criteria. Although the records report the veteran's history of chronic pain with radiation down the left side and flare-ups twice a week, and the March 2005 VA examination record reports that upper extremity strength could not be tested, the VA examinations consistently report no findings of spasm, sensory loss, or abnormal deep tendon reflexes, and the March 2000 and February 2001 VA examinations report that the neurological exam was normal, with no evidence of muscle atrophy, or motor function or reflex deficits. Additionally, the record includes no assessments of "severe" cervical radiculopathy or IDS. Based on the foregoing, the Board finds that the evidence does not most nearly approximate "severe" IDS during this period. In sum, the Board finds that a 20 percent rating, but no higher, is warranted prior to February 2, 2005, and a 30 percent rating, but no higher, is warranted effective February 2, 2005, based on the objective evidence of a worsening of symptomatology received on that date. TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The veteran applied for TDIU in September 1999. The Board notes that the veteran has provided conflicting histories as to when he was last gainfully employed. At his personal hearing, the veteran testified that he last worked full-time in 1995. See also October 2004 TDIU application form (last worked full-time in 1994). The September 1999 TDIU application reports that the veteran was then working 35 hours a week, with a monthly income of $2800 gross and a yearly income of approximately $30,000, however, and an October 2001 employer statement indicates that the veteran last worked for the company in December 1999. See September 1999 TDIU application; October 2001 request for employment information (veteran last worked at Supervalu December 11, 1999). See also November 1999 private treatment record (veteran reported that was "planning to leave his job"). The Board finds the latter evidence more credible and accepts December 11, 1999, as the date the veteran stopped being gainfully employed. (The Board notes that subsequent medical records report the veteran's history of last working in 2001. For the sake of this decision, however, the Board will accept December 11, 1999 as the date of unemployment for TDIU purposes). Prior to February 2, 2005 The records indicate that prior to June 24, 2004, the veteran has a combined rating of 50 percent for his cervical spine disability, lumbar spine disability, and kidney stones, and effective June 24, 2004, the veteran has a combined rating of 60 percent for his cervical spine disability, lumbar spine disability, kidney stones and irritable bowel syndrome. Because the veteran's combined rating never reached 70 percent, TDIU is only available if the veteran has been rendered unemployable solely due to the service-connected disability regardless of the total rating percentage currently assigned. In other words, TDIU is only available if an extraschedular rating is warranted. An extraschedular total rating based on individual unemployability may be assigned in the case of a veteran who fails to meet the percentage requirements but who is unemployable by reason of service-connected disability. 38 C.F.R. §§ 3.321, 4.16(b). For a veteran to prevail on a claim for a total compensation rating based on individual unemployability on an extraschedular basis, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). A January 2000 private treatment record reports the examiner's findings of bilateral ankle edema, "history of lumbar disc disease, cervical radiculopathy, severe brachial plexus neuropathy," multiple traumas, and "suspect right sciatic neuropathy secondary to compression of the nerve when sitting." See Pats record. The record indicates that the veteran "report[ed] that he cannot work," and the examiner noted that he "certainly agrees with" this opinion. A February 2001 unemployment benefits claim also reports a physician's opinion that the veteran was unable to work from February 2001 to June 2001 due to lower back and left shoulder pain and stiffness. See February 2001 Isaac record. A March 2005 VA examination record reports the veteran's history of being unable to "stand for long periods of time," drive, or turn his neck secondary to the service- connected spine disabilities. The record also reports the veteran's history of occupational impairments, including inability to write, inability to lift objects overhead, and inability to stand or walk, due to the non-service connected right knee, right ankle, bilateral hand, bilateral shoulder, and bilateral arm disorders. The evidence does not indicate that an extraschedular rating is warranted. While the service-connected disabilities cause some economic inadaptability, this is taken into account in the evaluation assigned, and the evidence of record includes no findings of unemployability due solely to the service connected disabilities. Although the record suggests that the veteran has not worked since 1999, there is no evidence that the veteran's lack of employment is due to his service- connected spine disabilities and kidney stone rather than one of his non-service connected disabilities, which include degenerative joint disease of multiple joints. The evidence of record does not include evidence that would take the veteran's case outside the norm. In view of the above, the Board finds that referring the claim to the Director of Compensation for extra-schedular consideration (as directed by 38 C.F.R. § 4.16(b)) is not warranted for the time period prior to February 2, 2005. Effective February 2, 2005 Based on the Board's decision above which grants a staged increase for cervical spine disability, the veteran has a combined rating of 70 percent, effective February 2, 2005; consequently, he meets the schedular threshold for determining entitlement to a TDIU rating. The only question remaining is whether there is evidence that the veteran is unable to secure substantially gainful occupation as the result of this disability. Medical records during this period indicate that the veteran's service connected disabilities include a history of kidney stones, severe limitation of motion of the lumbar and cervical spines with associated radiculopathies, and irritable bowel syndrome with daily episodes of diarrhea and episodes of constipation. Although the evidence does not include any competent medical opinions stating that these disabilities, rather than non-service connected disabilities, render the veteran unable to obtain or maintain gainful employment, the Board finds that based on the veteran's history of unemployment and the severity of his service- connected disabilities, and giving the benefit of the doubt to the veteran, TDIU is warranted effective February 2, 2005. ORDER A 30 percent rating, but no higher, is granted for the cervical spine disability from February 2, 2005, forward; and a rating of 20 percent, but no higher, is granted prior to February 2, 2005. TDIU is granted from February 2, 2005, forward, but denied prior to February 2, 2005. REMAND Initially the Board notes that the service medical records from the veteran's entire period of service have not been obtained. Administrative records associated with the claims file indicate that the RO requested the service medical records on numerous occasions. Responses from the National Personnel Records Center (NPRC) indicate that there were "no records at Code 13" and that future requests should be made at Code 11. Although the record indicates that the RO requested the service medical records via Code 11 in June 2004, no response was received from the NPRC. The Board finds that another request should be made. Further development is needed on the claim of service connection for Reiter's Syndrome. The veteran has contended that he had conjunctivitis and diarrhea from food poisoning or Shigella while stationed in Saudi Arabia and that he believes these conditions were really the initial symptoms of his Reiter's Syndrome. Service medical records report histories of dizziness, nausea, vomiting, diarrhea, and bloody stools while stationed in Saudi Arabia, and arm and leg pain. The evidence of record indicates that the veteran was diagnosed with gouty arthritis in May 2001, and subsequent treatment records report assessments of "reactive arthritis vs. arthropathy related to irritable bowel disorder." See May 2001 and June and July 2004 VA treatment records. A January 2006 VA examiner opined that it was as likely as not that the veteran had Reiter's syndrome based, at least on part, on the veteran's history of a positive test result for HLAB 27. The examiner did not state any findings as to whether the Reiter's syndrome was related to service. The record also includes a VA rheumatologist's opinion that, based on the veteran's history and review of the military medial records, the veteran "may have reactive arthritis associated with the bloody diarrhea (Shigella?)." See June 2004 VA treatment record. The Board notes that the VA rheumatologist's opinion is too speculative to warrant a grant of service connection. See 38 C.F.R. § 3.102. See also Slater v. Principi, 4 Vet. App. 43 (1993). Based on the VA rheumatologist's opinion, the evidence of in-service diarrhea, nausea, dizziness, and pain, and the lack of a prior opinion on the matter, however, the Board finds that an opinion is needed to determine whether reactive arthritis was incurred in service. See 38 U.S.C.A. § 5103A(d). Further development is also needed on the claims of service connection for a bilateral hand disorder. The evidence of record includes a finding that the veteran's reported hand numbness that "may be caused by degenerative joint disease and radiculopathy." See June 2004 VA treatment record. Additionally, the record reports a VA examiner's finding that the veteran had degenerative joint disease of the hands and that the degenerative joint disease was as likely as not secondary to his Reiter's Disease. See January 2006 VA examination record. The Board finds that a VA opinion should be obtained to determine the nature of the bilateral hand disorder and whether it is related to the cervical spine disorder, or, if service connected on remand, the reactive arthritis. See 38 U.S.C.A. § 5103A(d). Accordingly, the case is REMANDED for the following action: 1. The AMC should request the veteran's service medical records from the entire period of service via Code 11. If the records cannot be located, this fact should be noted in the record. 2. The AMC should return the claims folder to the examiner who conducted the January 2006 VA examination (or, if unavailable, to another appropriate VA reviewer). In an addendum, the reviewer should provide an opinion as to whether it is at least as likely as not (i.e., to at least a 50 percent degree of probability) that the veteran's reactive arthritis was incurred in service or is otherwise causally related to service. All testing deemed necessary by the examiner should be performed and the results reported in detail. The claims folder must be available for review by the examiner in conjunction with the examination and this fact should be acknowledged in the report. 3. The AMC should schedule the veteran for a VA examination, conducted by an appropriate specialist, to determine the nature and etiology of the veteran's bilateral hand disorder. For any disorder diagnosed, the examiner is requested to state whether it is at least as likely as not that the disorder was incurred in or is otherwise causally related to service or a service connected disability. All testing deemed necessary by the examiner should be performed and the results reported in detail. The claims folder must be available for review by the examiner in conjunction with the examination and this fact should be acknowledged in the report. 4. Thereafter, the AMC should readjudicate the appellant's claims. If the benefits sought on appeal remain denied, the appellant should be provided a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claim for benefits, to include a summary of the evidence and applicable law and regulations considered pertinent to the issue currently on appeal. An appropriate period of time should be allowed for response. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs