Citation Nr: 0812675 Decision Date: 04/16/08 Archive Date: 05/01/08 DOCKET NO. 99-04-300 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to a rating in excess of 10 percent for a service-connected a low back strain from April 11, 1998 through July 24, 2007. 4. Entitlement to a rating in excess of 20 percent for a service-connected low back strain from July 25, 2007. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs WITNESSES AT HEARING ON APPEAL The veteran and his wife ATTORNEY FOR THE BOARD B. Morton, Associate Counsel INTRODUCTION The veteran served on active duty from April 1971 to April 1973. This matter is before the Board of Veterans' Appeals (Board) from a November 1998 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied an increased rating in excess of 10 percent for a service connected low back disability, and declined to reopen a service connection claim for a bilateral knee disability. The RO issued a notice of the decision in November 1998, and the veteran timely filed a Notice of Disagreement (NOD) in December 1998. Subsequently, in January 1999 the RO provided a Statement of the Case (SOC), and thereafter, in February 1999, the veteran timely filed a substantive appeal. The RO issued a Supplemental Statement of the Case (SSOC) in December 2004. The veteran requested a Travel Board hearing on this matter, which was held in May 2006 where the veteran presented as a witness before the undersigned veterans law judge. A transcript of the hearing is of record. On appeal in September 2006, the Board reopened the veteran's claims for service connection for right and left knee disabilities, and remanded these issues as well as the increased rating claim for his service connection low back disability for additional development, to include providing proper Veterans Claims Assistance Act (VCAA) notice and a VA orthopedic examination, and obtaining Social Security Administration (SSA) records. Thereafter, in November 2007, the RO granted an increased rating for the low back disability to 20 percent from July 25, 2007, the date at which time the increase in disability became manifest. It issued a notice of this decision in November 2007 as well as an SSOC as to this claim and the issues of service connection for a bilateral knee disorder. The Board finds that the Appeals Management Center (AMC)/RO complied with the September 2006 Remand directive, and therefore the Board may proceed with its review of the appeal. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). The Board finds references to radiculopathy of the right lower extremity, which raises a claim for entitlement to a separate compensable rating for a neurological disability secondary to or associated with the veteran's service- connected low back strain. This matter is REMANDED to the RO via the AMC, in Washington, DC. (See remand appended to the decision below.) VA will notify the veteran if further action is required on his part. FINDINGS OF FACT 1. VA has made all reasonable efforts to assist the veteran in the development of his claims and has notified him of the information and evidence necessary to substantiate the claims addressed in this decision; of the information VA failed to provide or failed to provide in a timely fashion, any resulting prejudice has been rebutted. 2. The veteran's service medical records indicate that he was evaluated and treated on multiple occasions for bilateral knee pain and there is indication that he sustained injuries to both knees during that time; the veteran currently has a diagnoses of arthritis and patellar deformity of both knees and the evidence falls at least in relative equipoise as to whether any causal link exists between the in-service knee injuries and the current maladies. 3. From April 11, 1998 through July 24, 2007 the veteran's low back disability was manifested by essentially full range of motion, back pain and some muscle spasm but not by loss of lateral spine motion in any position, ankylosis or intervertebral disc syndrome (IDS), or, since September 26, 2003, forward flexion limited to 60 degrees or less, combined range of motion of the thoracolumbar spine to 120 degrees or less, or guarding severe enough to result in an abnormal gait or spinal contour. 4. From July 25, 2007 the veteran's low back disability has been manifested by limitation of flexion of the thoracolumbar spine to 40 degrees with pain at the extreme end but not by severe limitation of motion, ankylosis, IDS or severe lumbosacral strain with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. (The question of whether a separate compensable rating is warranted for radiculopathy or any other neurological impairment is addressed in the remand below.) CONCLUSIONS OF LAW 1. With application of the doctrine of reasonable doubt, service connection for residuals of a left knee injury, to include arthritis and deformity of the patella, is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2007). 2. With application of the doctrine of reasonable doubt, service connection for residuals of a right knee injury, to include arthritis and deformity of the patella, is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2007). 3. From April 11, 1998 through July 24, 2007, the criteria for a schedular rating in excess of 10 percent for a service connected low back strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5289, 5292, 5295 (prior to September 26, 2003) & Diagnostic Code 5237 (2007). 4. From July 25, 2007 the criteria for a schedular rating in excess of 20 percent for a service connected low back strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5289, 5292, 5295 (prior to September 26, 2003) & Diagnostic Code 5237 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The enactment of the VCAA, codified at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002), significantly changed the law prior to the pendency of these claims. VA has issued final regulations to implement these statutory changes. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). The VCAA provisions include an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits, and they redefine the obligations of VA with respect to the duty to assist the veteran with a claim. In the instant case, the Board has rendered a decision in favor of the veteran, finding that service connection for a left knee and a right knee disability is warranted, and therefore, a further discussion of the VCAA duties as to these claims is unnecessary at this time. The Board will address VCAA requirements as related to the veteran's increased rating claim below. a. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the September 2006 letter sent to the veteran by the RO adequately apprised him of most of the information and evidence needed to substantiate the claim, and of the information it failed to provide, any prejudice to the veteran has been rebutted. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. Sanders v. Nicholson, 487 F.3d 881, 886 (Fed. Cir. 2007) (outlining VCAA notice requirements); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (same). Additionally, during the pendency of this appeal, on March 3, 2006, the Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice 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 status; (2) existence of a 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 upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id., at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. In Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the Court of Appeals for Veterans Claims (Court) held VA must provide notice that includes: (1) notification that 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; (2) at least general notice of any specific measurement or testing requirements needed for an increased rating if the Diagnostic Code contains rating criteria that would not be satisfied by demonstrating only a general worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life; (3) notification that if an increase in disability is 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 0% to as much as 100% (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; and (4) notification 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, as outlined by the Court in Vazquez-Flores, supra. The September 2006 letter from the RO satisfies most of these mandates. It informed the veteran about the type of evidence needed to support his claims, namely, proof of that his service connected back disability had worsened. This correspondence clearly disclosed VA's duty to obtain certain evidence for the veteran, such as medical records, employment records and records held by any Federal agency, provided the veteran gave consent and supplied enough information to enable their attainment. It made clear that although VA could assist the veteran in obtaining these records, he carried the ultimate burden of ensuring that VA received all such records. This letter additionally apprised the veteran that VA would schedule a medical examination or obtain a medical opinion for him if the RO determined such to be necessary to make a decision on the claim. It also specifically asked the veteran to provide VA with any other supporting evidence or information in his possession, to include evidence demonstrating the impact of the disability on his employment, and apprised him of how VA calculates disability ratings and assigns effective dates in accordance with Dingess and Vazquez. The Board thus finds that the veteran was effectively informed to submit all relevant evidence in his possession, and that he received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board comments that the September 2006 letter did not specifically apprise the veteran at least generally of the range of motion measurements required to show increased disability under applicable Diagnostic Codes, as contemplated by Vazquez. Where such an error occurred, the Board must presume that the error was prejudicial, and VA bears the burden of rebutting said presumption. Sanders, 487 F.3d at 886, 889 (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 891 ("this opinion does not . . . change the rule that reversal requires 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." Mayfield, supra; accord Sanders, supra. "[A]n error is not prejudicial when [it] did not affect 'the essential fairness of the [adjudication],'" see Mayfield, supra, at 121, and non- prejudicial error may be proven by a showing that "the purpose of [VCAA] notice was not frustrated, e.g., by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant, (2) that a reasonable person could be expected to understand from the [defective] notice what was needed, or (3) that a benefit could not have been awarded as a matter of law." Sanders, supra, at 889; accord Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (determining that no prejudicial error to veteran resulted in defective VCAA notice when the veteran, through his counsel, displayed actual knowledge of the information and evidence necessary to substantiate his claim). Accordingly, "there could be no prejudice if the purpose behind the notice has been satisfied . . . that is, affording a claimant a meaningful opportunity to participate effectively in the processing of [the] claim. . . ." Mayfield, supra, at 128. The Board determines that despite the September 2006 letter's inadequate notice pertaining to at least general information of any specific measurement or testing requirements needed for an increased rating, any presumed prejudice to the veteran has been rebutted. Specifically, at his May 2006 Travel Board hearing, the veteran, through his accredited representative, demonstrated actual knowledge of the applicable Code of Federal Regulation Diagnostic Codes pertaining to the back. See Hearing Transcript at 3 (specifically referencing and citing to Diagnostic Codes relating to back disabilities). Under such a circumstance, the Board concludes that the presumed prejudice to the veteran has been rebutted. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." VA did not provide such notice to the veteran prior to the November 1998 RO decision that is the subject of this appeal in its September 2006 letter. The RO cured this defect, however, by providing this complete VCAA notice together with readjudication of the claim, as demonstrated by the November 2007 SSOC. 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 notification defect). The veteran thus was not prejudiced by any defect in timing, as "the purpose behind the notice has been satisfied . . . that is, affording a claimant a meaningful opportunity to participate effectively in the processing of [the] claim. . . ." Mayfield, 19 Vet. App. at 128. b. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the veteran of its duty to assist in obtaining records and supportive evidence, and the veteran in fact did receive a July 2007 VA examination, which was thorough in nature. This examination and the other medical evidence of record contain findings that are adequate for rating the veteran's low back strain. (As noted above, the instant Board decision grants the other two claims on appeal, service connection for right and left knee disabilities.) The Board finds that the medical evidence of record is sufficient to resolve this appeal, and the VA has no further duty to provide an examination or opinion. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the veteran, and thus, no additional assistance or notification was required. The veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, 4 Vet. App. at 392-94. II. Service Connection a. Law & Regulations The Court has held that "[f]or service connection to be awarded, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of an 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 disease or injury." Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006); accord Disabled Am. Veterans v. Sec'y of Veterans Affairs, 419 F.3d 1317, 1318 (Fed. Cir. 2005); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). If the veteran fails to demonstrate any one element, denial of service connection will result. Disabled Am. Veterans, supra; Coburn, supra. With respect to the "current disability" prong, the Court has recognized that, "[i]n the absence of proof of a present disability there can be no valid claim" of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Caluza v. Brown, 7 Vet. App. 498, 505 (1995) (recognizing that "[a] service-connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability"); see also Chelte v. Brown, 10 Vet. App. 268, 271, 272 (1997) (holding that the veteran's claim was not well grounded when the evidence "establishe[d] only that the veteran had a [disability] in the past, not that he has a current disability"). Turning to the second, "incurrence in or aggravation by service" prong, the Court has expressed that "[s]ervice connection for VA disability compensation . . . will be awarded to a veteran who served on active duty during a period of war . . . for any disease or injury that was incurred in or aggravated by" such service. Caluza, 7 Vet. App. at 505. VA may grant service connection, despite a diagnosis after discharge, when all the evidence, including that pertinent to service, establishes that the veteran incurred the disease during service. See 38 C.F.R. § 3.303(d); accord Caluza, supra ("When a disease is first diagnosed after service, service connection may nevertheless be established by evidence demonstrating that the disease was in fact 'incurred' during the veteran's service, or by evidence that a presumption period applied"). With respect to the third, "nexus" prong, the veteran must demonstrate through medical evidence that "a causal relationship" exists between the present disability and an in-service event. Shedden, 381 F.3d at 1167. Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence must demonstrate that the claim is plausible. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Mere lay assertions of medical status do not constitute competent medical evidence. Moray v. Brown, 5 Vet. App. 211, 214 (1993) ("lay persons are not competent to offer medical opinions"). Alternatively, a veteran can establish a nexus between service and the current disability by offering 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, 120 (1999); Savage v. Gober, 10 Vet. App. 488, 495 (1997). Additionally, 38 C.F.R. § 3.303(b) "provides an alternative method of demonstrating entitlement to service connection" for chronic conditions. Rose v. West, 11 Vet. App. 169, 172 (1998) (Emphasis in original); accord Cotant v. Principi, 17 Vet. App. 116, 133 (2003); Savage, 10 Vet. App. at 495-96 (noting that § 3.303(b) provides a "substitute way of showing in-service incurrence and medical nexus") (Emphasis in original); see 38 C.F.R. § 3.303(b) ("Chronicity and continuity"). It provides that "[w]ith chronic disease shown as such in service . . . subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes." 38 C.F.R. § 3.303(b); accord Savage, supra, at 495 (noting that a veteran may employ § 3.303(b) "when the evidence demonstrates: (1) that the veteran had a chronic disease in service, or during an applicable presumption period . . . and (2) that the veteran presently has the same condition"). This does not mean "that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date." 38 C.F.R. § 3.303(b). It does mean, however, that in order to demonstrate the existence of a chronic disease in service, the record must reflect "a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word 'Chronic.'" 38 C.F.R. § 3.303(b). Further, "[w]hen the disease identity is established . . . there is no requirement of evidentiary showing of continuity." 38 C.F.R. § 3.303(b). However, "[c]ontinuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim." 38 C.F.R. § 3.303(b). 38 U.S.C.A. § 5107 sets forth the standard of proof applied in decisions on claims for veterans' benefits. A veteran will receive the benefit of the doubt when an approximate balance of positive and negative evidence exists. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Thus, when a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. Wells v. Principi, 18 Vet. App. 33, 36 (2004); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). A claim will be denied only if a preponderance of the evidence is against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519-20 (1996). b. Factual Background In the veteran's March 1971 Report of Medical Examination for Induction, he received a normal clinical evaluation of the lower extremities. A March 1972 service medical record indicates that the veteran complained of pain in the knees. He indicated that he had injured the knees twice the week before while playing basketball, and that he chronically felt swelling and pain when engaging in sports for several hours. At this time, the knees were stable without effusion, and the examiner offered the impression of early chondromalacia patella. The veteran had similar reports of bilateral knee pain in April 1972 and June 1972. He exhibited crepitus of the left patella with tenderness over the mid-meniscus of the right leg in April 1972, but a Radiographic Report indicated that views of both knees revealed no evidence of bone, joint or soft tissue abnormality. A clinical history of left chondromalacia of the patella and a mid-meniscus injury to the right knee was noted. A February 1973 Report of Medical Examination for Discharge reflects a normal clinical evaluation of the lower extremities. In the accompanying Report of Medical History, the veteran made no indication that he had knee trouble. A September 1973 VA Radiographic Report indicates that the veteran sustained an injury to the bilateral knees during service while playing sports. Studies of both knees showed no evidence of fracture, dislocation or other bone or joint pathology, and a physical examination revealed symmetrical knees without deformity, tenderness, redness, swelling or limitation of motion. At this time, the veteran reported that he experienced aching of the knees during rigorous sport activity, but reported none during the physical examination, which included complete knee bending. A June 1988 Health Unit Case record discloses that the veteran had knee pains. Other such records dated October 1990, April 1991, January 1992, and February 1992 state that the veteran had a knee wrap and knee pain. November 1990, August 1997 and September 1997 private medical notes indicate that the veteran had pain or swelling of the lower extremities and legs. As reflected in January 1998 VA medical reports, the veteran had bilateral knee pain with right knee swelling and arthralgia. A February 1998 VA medical report indicates that the veteran had arthritis of the bilateral knees, and he indicated as such in his February 1999 substantive appeal. The veteran complained of bilateral knee pain as noted in May 1998 and January 1999 VA medical records. A physical examination in January 1999 revealed no deformity or edema, and a January 1999 MRI of the left knee revealed a probably normal ACL; a diminutive medial meniscus, without definite tear; and minimal effusion with superficial subcutaneous edema. The examiner could not rule out a chronic tear, and she opined that the veteran had stress versus chronic post- traumatic osteophytes arising from the anteroinferior aspect of the patella. She concluded that "[t]his may be related to patient history of remote trauma to the knees ('fall on knees about 20 years ago')." As reflected in a February 1999 VA medical report, the veteran complained of bilateral knee pain, with locking of the left knee. A VA medical examination report, also dated February 1999, conveys that the veteran had degenerative joint disease (DJD) of the bilateral knees, and a possible right lateral meniscus tear and left medial meniscus tear. An accompanying MRI of the right knee revealed a possible partial versus intrasubstance ACL tear; possible chronic PCL tear (mid aspect); questionable lateral meniscal posterior horn inferior degenerative tear; small effusion; anterior superficial subcutaneous edema; and patellofemoral arthritis with Peligrini-Stieda inferior patellar pole asymmetric spurring. In July 2007 the veteran underwent a VA examination of the knees. The clinician reviewed the claims file, to include the veteran's service medical records. A physical examination revealed that the veteran's medial and lateral meniscus were intact, as were his ACL and PCL. He exhibited a full range of motion of the left knee. Based on the clinician's review of the veteran's claims file and the physical examination he concluded that it "did not show any right knee or left knee disability is not causally linked to any incidents of active duty. . . . The patient has functional impairment due to nonservice-connected stroke with right hemiparesis and not connected to low back strain. Right knee examination shows mild limitation of range of motion and chronic outcome of nonservice-connected right hemiparesis. Left knee shows functional range of motion adequate, and stability is adequate. Hence, mild changes in the knee are due to aging process." A companion radiology report indicates that the right knee evidenced no acute fracture or dislocation, although the veteran had mild osteoarthritis in the medical joint space, moderate joint effusion, and "[d]eformity of the patella, likely secondary to previous trauma." c. Discussion The Board determines that the evidence falls at least in relative equipoise with respect to the veteran's claims for service connection for left and right knee disabilities, in which case, he receives the benefit of the doubt in his favor. 38 U.S.C.A. § 5107(b). In particular, as reflected in his service medical records, the veteran sought treatment for bilateral knee symptoms following apparent knee injuries on several occasions from March 1972 to June 1972 while on active duty. In addition, as reflected in post-service medical reports and as noted by the most recent July 2007 VA examiner, the veteran has received diagnoses of DJD or arthritis and patellar deformity of both knees and there is a history of meniscal tearing of the knees. As such, the Board determines that he currently has a bilateral knee disorder. The only question remaining, therefore, amounts to whether any of the veteran's current bilateral knee disorders is causally linked to the documented in-service bilateral knee pain and injuries. In this regard, the Board notes that the record contains competing medical opinions with respect to whether any such nexus exists. In such a circumstance, the Board must determine how much weight to afford each opinion. See Cathell v. Brown, 8 Vet. App. 539, 543(1996) (noting that "[i]t is the responsibility of the B[oard] . . . to assess the credibility and weight to be given to evidence"); Guerrieri v. Brown, 4 Vet. App. 467, 471 (1993). The Board may place greater weight on one medical professional's opinion over another, depending on factors such as the reasoning employed, medical expertise, the thoroughness and detail of the opinion, whether or not, and the extent to which, they reviewed prior clinical records or the claims file, and other evidence. See Guerrieri, supra, at 470-71 ("The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches"); accord Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board's determination in this regard must be explained in a statement providing adequate reasons and bases. Owens v. Brown, 7 Vet. App. 429, 433 (1995) (noting that the Board may "favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases"). As noted above, the July 2007 VA examiner determined, after conducting a physical examination and thoroughly reviewing the claims file, that any current bilateral knee disorder was age-related or related to the veteran's nonservice-connected stroke, which would weigh against the veteran's claims. On the other hand, the July 2007 radiologist, after reviewing X- ray film, concluded the opposite, namely, that a deformity of the patella "likely [was] secondary to previous trauma," while the January 1999 radiologist suggested that the veteran's knee disorder "may be related to . . . remote trauma to the knees" during active service. The July 2007 opinion supports the claims for service connection and the latter opinion from a radiologist, while speculative, provides additional support when read in conjunction with the clinical findings and the July 2007 opinion. While neither radiologist provided detailed rationale for their conclusions, the July 2007 VA examiner likewise did not supply extensive rationale for his unfavorable determination. Most significantly, although the July 2007 examiner noted the veteran's documented in-service knee injuries, he did not explain why said injuries, instead of age or residuals of a stroke, could not have caused the current disorders, but appeared to summarily dismiss any such favorable connection without discussion. When viewing this evidence in totality, the Board concludes that the positive and negative opinions roughly balance each other, in which case, the veteran receives the benefit of the doubt to his advantage. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board finds that service connection is warranted for residuals of right and left knee injuries, to include arthritis and patellar deformity of both knees, which were diagnosed upon the most recent VA examination. III. Increased Rating a. Law & Regulations 38 U.S.C.A. § 1155 sets forth provisions governing disability ratings, and it directs the Secretary to "adopt and apply a schedule of ratings of reductions in earning capacity from specific injuries or combination of injuries." The schedule of ratings must provide for ten grades of disability, and no more, ranging from 10 percent to 100 percent in 10 percent intervals, upon which the payments of compensation shall be based. 38 U.S.C.A. § 1155. In addition, "the Secretary shall from time to time readjust this schedule of ratings in accordance with experience." 38 U.S.C.A. § 1155. To this end, the Secretary promulgated 38 C.F.R. § 3.321(a), which requires the use of a "Schedule for Rating Disabilities . . . for evaluating the degree of disabilities in claims for disability compensation . . . and in eligibility determinations." The provisions contained in the rating schedule approximate the average impairment in earning capacity in civil occupations resulting from a disability. 38 C.F.R. § 3.321(a); accord 38 U.S.C.A. § 1155 ("The ratings shall be based, as far as practicable, upon average impairments of earning capacity resulting from such injuries in civil occupations"). Separate diagnostic codes pertain to the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Additionally, the Board comments that where, as here, "there is no clearly expressed intent [by the veteran] to limit the appeal to entitlement to a specific disability rating for the service-connected condition, the . . . BVA [is] required to consider entitlement to all available ratings for that condition." AB v. Brown, 6 Vet. App. 35, 39 (1993) (Emphasis added). 38 C.F.R. § 4.71a sets forth the schedule of ratings for the musculoskeletal system, to include disabilities of the spine. At the time the veteran filed his increased rating claim in April 1998, the following relevant provisions in 38 C.F.R. § 4.71a relating to evaluations of the spine, were in effect: Under Diagnostic Code 5289, a veteran would receive a rating of 40 percent for favorable ankylosis of the lumbar spine and 50 percent for unfavorable ankylosis. 38 C.F.R. § 4.71a, Diagnostic Code 5289 (1997). Pursuant to Diagnostic Code 5292, a veteran would receive 10 percent, 20 percent or a maximum rating of 40 percent for slight, moderate or severe limitation of motion of the lumbar spine respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (1997). Under Diagnostic Code 5295, a veteran would generate a 10 percent evaluation for a lumbosacral strain with characteristic pain on motion, 20 percent for lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position, and a maximum rating of 40 percent for severe lumbosacral strain, with listing of whole spine to opposite side, positive Goldwaithe's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo- arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (1997). With respect to evaluations for intervertebral disc syndrome (IDS), as explained in more detail below, service connection is not in effect for disc disease of the thoracic or lumbar spine. In fact, the overwhelming preponderance of the medical evidence is against such a diagnosis. Accordingly, Diagnostic Codes 5293 (to include as amended on September 23, 2002) and 5243 (effective from September 26, 2003) are not applicable to this appeal. Subsequently, during the pendency of this appeal, 38 C.F.R. § 4.71a and accompanying Diagnostic Codes underwent revisions, effective from September 23, 2002 and September 26, 2003. See 68 Fed. Reg. 51454 (Aug. 27, 2003); 67 Fed. Reg. 54345 (Aug. 22, 2002). As a general matter, "[c]ongressional enactments and administrative rules will not be construed to have retroactive effect unless their language requires this result." Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003) (internal quotation marks and citation omitted). Accordingly, when a new statute or regulation has been promulgated while a claim is still pending before VA, the new provision will apply only to the period on and after its effective date, unless otherwise clearly indicated by the statute or regulation, while the former provision will apply to the pending claim prior to that effective date. See id.; VAOPGCPREC 7-03. With these principles in mind, the Board recognizes that because the issue in this appeal spans both before and after the amendments, the Board must evaluate the veteran's disability under the pre-September 2002 and 2003 amendment versions of 38 C.F.R. § 4.71a as well as the post- September 2002 and 2003 amendment versions. See VAOPGCPREC 3-2000 (Apr. 10, 2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Relevant to the instant case, after September 26, 2003, a veteran, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, will receive a 40 percent rating when he exhibits forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237, 5242 (2007). The next higher rating of 50 percent will be awarded when a veteran displays unfavorable ankylosis of the entire thoracolumbar spine, and a veteran will generate the maximum 100 percent evaluation if he has unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237, 5242 (2007). The Board additionally comments that Note (2) accompanying the General Rating Formula for Diseases and Injuries of the Spine indicates that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, Note (2) (2007). The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Note (2) (2006). DeLuca Factors The Board will also consider whether this case presents other evidence that would support a higher rating on the basis of functional limitation due to weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.10, 4.40 ("Disability of the musculoskeletal system is primarily the inability, due to damage . . in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements"), 4.45, 4.59 (2006); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of a claimant. 38 C.F.R. § 4.40; accord Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Additionally, "[w]eakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled." 38 C.F.R. § 4.40. The Board observes that 38 C.F.R. § 4.40 does not require a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). Where entitlement to compensation has already been established and an increase in the severity of the disability is at issue, as here, "the relevant temporal focus . . . is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mayfield, -- Vet. App.--, 2007 WL 4098218, * 3; see also Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In this regard, the Court has recognized that "[i]f VA's adjudication of any increased-rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased- rating claim was filed until a final decision on that claim is made." Hart, supra, at *3. Accordingly, "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Id. In addition, "[w]here 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." 38 C.F.R. § 4.7. b. Factual Background January 1998, February 1998, May 1998 and August 1998 VA medical reports note the veteran's complaints of back pain for which he took medication. The veteran conveyed that he had constant back pain in his February 1999 substantive appeal. An August 1998 VA physical examination of the back revealed that the veteran had a normal spine, with some mild tenderness subjectively in the low back in the L5, S1 region. He exhibited normal flexion, extension and lateral movement throughout, without significant pain on palpation except for a little bit of tenderness in the L5, S1 area. Motor and sensory examinations were grossly intact, along with reflexes. He had no generalized muscle weakness or wasting. Based on these data, the physician diagnosed the veteran with lumbosacral sprain, currently not exacerbated. He also noted that the veteran performed certain activities throughout the day for his job, to include, sitting, standing, bending, walking, pushing and pulling. March 2004 private medical records indicate that the veteran complained of low back pain. He had no associated numbness or swelling at this time, but he complained of tingling to the legs. A radiology report indicated that the veteran had no fracture, and his discs were well-maintained, without significant arthritic changes noted. The impression was a normal lumbar spine. In a February 2006 Statement in Support of Claim, the veteran stated that he had arthritis of the knees and back. At his May 2006 Travel Board hearing the veteran testified that he had back cramps manifested by tightening up and an inability to stand straight up. Hearing Transcript at 3. He stated that he "couldn't really go to work and do anything" at this time. Hearing Transcript at 3. He had worked as a postal clerk, which required him to sort mail Hearing Transcript at 4. The veteran's wife also testified that in recent years, he had experienced increased pain in the back as well as muscle spasms three to four times weekly, and the veteran stated that he had radiating pain down the right leg with pain in the knees as well as a limp. Hearing Transcript at 5, 6, 7. He reported having flare-ups of back pain, but stated that he had retired from his job due to having a stroke. Hearing Transcript at 8. In July 2007 the veteran underwent a VA examination to assess the current severity of his service connected back disorder. The examiner reviewed the claims file, and noted that the veteran had right upper extremity weakness, nonfunctional and right foot drop, although he did not make clear whether these symptoms were attributable to the veteran's back disability or stroke. The veteran had no bowel or bladder complaints. At this time, he exhibited forward flexion to 40 degrees; extension to 20 degrees; left lateral flexion to 30 degrees; right lateral flexion to 20 degrees; left lateral rotation to 30 degrees; and right lateral rotation to 22 degrees. The veteran had pain at the end of range of motion in flexion and extension but not side to side. Repetitive motion caused a mild increase of pain, but no essential increase in fatigue, weakness or lack of endurance. The veteran had no objective evidence of painful motion or weakness, but the clinician detected some spasm. He had tenderness in the paralumbar muscles, right side, with guarding, and the examiner attributed the veteran's abnormal gait to his stroke with right hemiparesis. A sensory neurological examination revealed no deficit, and the examiner concluded that the veteran had no IDS. He diagnosed the veteran with chronic low back pain or low back strain, and stated that the veteran "is at least as likely as not there is no additional functional loss as a result of service-connected lumbosacral sprain . . . Any back changes found are due to chronic nonservice-connected back strain or pain is at least not a continuation or secondary to service-connected back strain or secondary to knee injury or secondary changes in the knee due to changes in the knee injury, but some effect in the spine is due to nonservice-connected stroke condition." A companion X-ray report revealed mild osteoarthritic changes of the lumbar spine. c. Discussion The Board determines that the evidence preponderates against a schedular rating in excess of 10 percent for the veteran's service-connected low back strain from April 11, 1998 through July 24, 2007. In particular, at no time within this period has the veteran exhibited ankylosis of the lumbar spine (Diagnostic Code 5289) and service connection is not in effect for IDS. Thus, a higher rating is not warranted under Diagnostic Codes 5289 or 5293 (to include as amended in September 2002), or under the current criteria found in Diagnostic Codes 5237 or 5243. On the question of IDS, the Board notes that the overwhelming preponderance of the evidence is against a diagnosis of disc disease of the lumbar spine or IDS with the most recent examiner in July 2007 specifically ruling out such a diagnosis. In addition, while the veteran complained of back pain and exhibited tenderness with a normal range of motion as of August 1998, and reported having muscle spasms and flares as of May 2006, as explained in more detail below, such symptomatology does not support a rating in excess of 10 percent under either the old or current (since September 26, 2003) rating criteria in the absence of other abnormal findings. Turning first to the "old" criteria (as noted above, applicable here for the entire period of time at issue because the veteran filed his claim prior to the enactment of the revised criteria), the Board determines that the evidence dated prior to July 25, 2007 (the effective date of the RO's rating decision increasing the evaluation to 20 percent) does not demonstrate that the veteran had "moderate" limitation of motion of the lumbar spine, as would be required under Diagnostic Code 5292, given his essentially full range of motion as documented in August 1998 and again in March 2004. Also, while the veteran reportedly had weekly muscle spasms as of May 2006, the evidence of record does not support a finding that he had loss of lateral spine motion, unilateral, in standing position, or in any other position, prior to July 25, 2007, as would be required for a 20 percent rating under Diagnostic Code 5295. Similarly, the evidence weighs against his claim for a rating in excess of 10 percent from September 26, 2003 (effective date for revised rating criteria) through July 24, 2007, under the current criteria, as he did not exhibit forward flexion limited to 60 degrees or less, combined range of motion of the thoracolumbar spine to 120 degrees or less, or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, as would typify a 20 percent evaluation. Accordingly, a schedular rating in excess of 10 percent is not warranted for the veteran's lumbar strain prior to July 25, 2007. The Board also determines that the evidence weighs against a rating in excess of 20 percent for the veteran's low back strain from July 25, 2007. Specifically, the July 2007 VA examination report did not indicate that the veteran had ankylosis or IDS, as would be required for increased ratings in excess of 20 percent under Diagnostic Codes 5289 and 5293 (1997) or Diagnostic Codes 5243 or 5237 (2007). In addition, while the veteran displayed limitation of forward flexion of the thoracolumbar spine to 40 degrees, the examiner did not determine that he had forward flexion limited to 30 degrees or less, even when considering DeLuca factors of pain, weakness or fatigue, as would be required for the next higher evaluation of 40 percent under Diagnostic Code 5237. The most recent VA examiner specifically reported that the veteran had pain at the end of the motions provided, to include forward flexion to 40 degrees. In this regard, the Board also cannot find that the veteran had "severe" limitation of motion of the lumbar spine, as would typify a 40 percent evaluation under Diagnostic Code 5292 (1997) or a "severe" lumbosacral strain, with listing of whole spine to opposite side, positive Goldwaithe's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, irregularity of joint space or abnormal mobility on forced motion, as required under Diagnostic Code 5295 (1997). Instead, while the July 2007 VA examiner noted the veteran's abnormal gait, he attributed this abnormality to residuals of the veteran's strokes. In light of such evidence, the Board must deny this claim. The question of whether a separate compensable rating is warranted for radiculopathy or any other neurological impairment secondary to or associated with the veteran's low back strain that may be present is addressed in the remand below. For the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for a higher rating for the veteran's low back strain for either period of time in question. Accordingly, the benefit of the doubt doctrine does not apply to the instant case and the claim for a rating in excess of 10 percent for a service connected low back strain from April 11, 1998 through July 24, 2007, or to rating in excess of 20 percent thereafter, must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"). Extraschedular Ratings As required by Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), the Board has considered the potential application of various provisions of Title 38 of the Code of Federal Regulations, whether or not the veteran raised them, including § 3.321(b)(1), which governs extraschedular ratings. See also Hupp v. Nicholson, 21 Vet. App. 342, 355 (2007). The Board finds that the evidence of record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1) (2007). There has been no showing by the veteran that his service-connected back disability has necessitated frequent hospitalizations beyond that contemplated by the rating schedule or has caused a marked interference with employment; instead, at his Travel Board hearing the veteran attested that his nonservice connected stroke and residuals thereof had impeded his work, not his back disorder. Hearing Transcript at 8 (stating that his two strokes had caused him to retire from his job at the post office). In the absence of such factors, the criteria for submission for assignment of an extraschedular rating for his back disability pursuant to 38 C.F.R. § 3.321(b)(1) are not satisfied. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for residuals of a left knee injury, to include arthritis and deformity of the patella is granted. Service connection for residuals of a right knee injury, to include arthritis and deformity of the patella is granted. A rating in excess of 10 percent for a service connected low back strain from April 11, 1998 through July 24, 2007 is denied. A rating in excess of 20 percent for a service connected low back strain from July 25, 2007 is denied. REMAND The Board finds that additional development is warranted to address the merits of the veteran's neurological manifestations stemming from his service connected back disability. 38 C.F.R. § 19.9 (2007). As noted above, the veteran has complained of tingling in the legs, both in March 2004 and May 2006, but the July 2007 VA examiner determined that the veteran had no sensory neurological deficit. The Board therefore cannot ascertain whether the veteran currently experiences any neurological problems related to his service connected back disorder, and accordingly, must obtain a VA examination to resolve this issue. Accordingly, the case is remanded for the following action: 1. The AMC/RO must review the record and ensure compliance with all notice and assistance requirements set forth in the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.159 (2007). Notice consistent with 38 U.S.C.A § 5103(a) and 38 C.F.R. § 3.159(b)(1) with respect to the claims must: (a) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim for the benefit sought; (b) inform the claimant about the information and evidence that VA will seek to provide; (c) inform the claimant about the information and evidence the claimant is expected to provide; and (d) request that the claimant provide any evidence in the claimant's possession that pertains to the claim. The AMC/RO should provide the veteran with VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that includes an explanation as to the information or evidence needed to establish ratings and effective dates for the benefit sought as outlined by the Court of Appeals for Veterans Claims in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006). The AMC/RO should also provide proper VCAA notice with respect to an increased rating claim that includes: (1) notification that 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; (2) at least general notice of any specific measurement or testing requirements needed for an increased rating if the Diagnostic Code contains rating criteria that would not be satisfied by demonstrating only a general worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life; (3) notification that if an increase in disability is 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 0% to as much as 100% (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; and (4) notification 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, as outlined by the Court in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). 2. The veteran must be afforded a VA neurological examination for the purpose of determining whether he currently suffers from radiculopathy or other neurological disorders attributable to his service connected back disability. The claims file should be sent to the examiner for his or her review. Following a review of the relevant medical evidence in the claims file, obtaining a history from the veteran, the physical examination, any diagnostic studies are deemed necessary, and any additional specialty examinations that are warranted, the clinician is requested to answer the following question: (a) If the clinician determines that the veteran currently suffers from neurological deficiencies, such as numbness or tingling of the lower extremities, is it at least as likely as not (50 percent or greater probability) that said neurological deficits are causally related to his service connected low back strain? The clinician 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; less likely weighs against the claim. The examiner is also requested to provide a rationale for any opinion expressed. The clinician is advised that if a conclusion cannot be reached without resort to speculation, s/he should so indicate in the examination report. 3. Then, after completion of any other notice or development indicated by the state of the record, with consideration of all evidence added to the record subsequent to the last SSOC, the AMC/RO must adjudicate the claim of whether there is neurological impairment secondary to or associated with the veteran's service-connected low back strain, to include but not limited to radiculopathy of the right lower extremity and, if so, whether such impairment warrants a separate compensable rating. If the veteran remains dissatisfied with the outcome, the AMC/RO should issue an appropriate SSOC and provide an opportunity to respond. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369, 370 (1999) (per curiam). 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. ____________________________________________ R. F. WILLIAMS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs