Citation Nr: 0903196 Decision Date: 01/30/09 Archive Date: 02/09/09 DOCKET NO. 05-23 287 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for Parkinson's disease prior to July 4, 2006. 2. Entitlement to an initial rating in excess of 30 percent for Parkinson's disease as it has affected the right upper extremity from December 2, 2006. 3. Entitlement to an initial rating in excess of 20 percent for Parkinson's disease as it has affected the left upper extremity from December 2, 2006. 4. Entitlement to an initial rating in excess of 20 percent for Parkinson's disease as it has affected the left lower extremity from December 2, 2006. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Nancy S. Kettelle, Counsel INTRODUCTION The veteran had active service from August 1986 to September 1994, from February 1995 to April 1995, from April 2002 to May 2002, from August 2002 to September 2002, and from July 2006 to December 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. In that rating decision, the RO granted service connection for undiagnosed illness manifested by tremor in the left arm, hand, fingers, and left leg and assigned a 30 percent rating effective the date of receipt of the service connection claim in January 2003. The veteran's disagreement with the 30 percent rating led to this appeal. In his notice of disagreement, which was received at the Honolulu RO in November 2004, the veteran said his tremors had affected his right arm and fingers. In a statement received at the RO in April 2005, the veteran referred to the 30 percent rating for tremors to the left side of his body and said he would like an increase or new rating for his right arm, hand, fingers, and right leg. In a rating decision dated in June 2006, the Honolulu RO continued the 30 percent rating but changed the identification of the disability from undiagnosed illness manifested by tremor in the left arm, hand, fingers, and left leg to reflect the diagnosis of Parkinson's disease. The veteran continued his appeal concerning the initial 30 percent rating. During the course of the appeal the veteran moved to Nevada. In a supplemental statement of the case dated in September 2007, the RO in Reno, Nevada, continued the 30 percent rating for Parkinson's disease previously rated as undiagnosed illness manifested by tremor in the left arm, hand, finger, and left leg. In a rating decision dated in December 2007, the Reno RO granted service connection for dystonia secondary to medication for treatment of the veteran's service-connected Parkinson's disease, but said a separate rating would not be assigned because it was determined to be part and parcel of the evaluation for Parkinson's disease. In a rating decision dated in August 2008, the Reno RO discontinued the 30 percent rating for Parkinson's disease effective July 4, 2006, the date the veteran returned to active duty. The RO assigned a separate 30 percent rating for tremors of the right upper extremity associated with Parkinson's disease effective from December 2, 2006, the day following the end of the veteran's active service. The RO also assigned a separate 20 percent rating for tremors of the left upper extremity associated with Parkinson's disease effective from December 2, 2006, and a separate 20 percent rating for bradykinesia and weakness left lower extremity associated with Parkinson's disease effective from December 2, 2006. The RO issued a supplemental statement of the case reflecting its decision. In its September 2008 letter forwarding the supplemental statement of the case to the veteran, the RO notified him that its decision was considered a partial grant of benefits sought on appeal for the evaluation of Parkinson's disease and that if this decision satisfied his appeal, he was requested to complete and return an enclosed "VA Form Appeal Response" within 30 days. The veteran continued his appeal. FINDINGS OF FACT 1. Prior to July 4, 2006, manifestations of the veteran's Parkinson's disease as it affected his right (major) upper extremity consisted of tremors with disability equivalent to mild incomplete paralysis of the median nerve. 2. Prior to July 4, 2006, manifestations of the veteran's Parkinson's disease as it affected his left (minor) upper extremity consisted of tremors and some rigidity and weakness, with functional impairment equivalent to moderate incomplete paralysis of the median nerve. 3. Prior to July 4, 2006, manifestations of the veteran's Parkinson's disease as it affected his left lower extremity included trembling and a left limp with the left foot dragging after walking more than short distances; there was functional impairment equivalent to moderate incomplete paralysis of the sciatic nerve. 4. From December 2, 2006, manifestations of the veteran's Parkinson's disease as it affects his right (major) upper extremity include tremors, some rigidity, and intermittent inability to write legibly or hold food on a fork, along with difficulty fastening buttons and using zippers; there is functional impairment equivalent to severe incomplete paralysis of the median nerve. 5. From December 2, 2006, manifestations of the veteran's Parkinson's disease as it affects his left (minor) upper extremity include tremors, weakness, and difficulty with fine motor skills equivalent to moderate incomplete paralysis of the median nerve. 6. From December 2, 2006, manifestations of the veteran's Parkinson's disease as it affects his left lower extremity include stooped posture, occasionally freezing gait, some bradykinesia, stiffness, and weakness of the left leg with left foot dragging after walking more than short distances; in combination, and with resolution of reasonable doubt in favor of the veteran, the manifestations approximate moderately severe incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent rating for manifestations of the veteran's Parkinson's disease as it affected his right (major) upper extremity were met for the period prior to July 4, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8004, 8515 (2008). 2. The criteria for an initial 20 percent rating for manifestations of the veteran's Parkinson's disease as it affected his left (minor) upper extremity were met for the period prior to July 4, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8004, 8515 (2008). 3. The criteria for an initial 20 percent rating for manifestations of the veteran's Parkinson's disease as it affected his left lower extremity were met for the period prior to July 4, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8004, 8520 (2008). 4. The criteria for an initial 50 percent rating for manifestations of the veteran's Parkinson's disease as it has affected his right (major) upper extremity have been met from December 2, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8004, 8515 (2008). 5. The criteria for an initial rating in excess of 20 percent for manifestations of the veteran's Parkinson's disease as it has affected his left (minor) upper extremity from December 2, 2006, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8004, 8515 (2008). 6. The criteria for an initial 40 percent rating for manifestations of the veteran's Parkinson's disease as it has affected his left lower extremity have been meta from December 2, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.7, 4.124a, Diagnostic Codes 8004, 8520 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA duties to notify and assist Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2008). 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 must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his or her possession that pertains to the claim. See 38 C.F.R. § 3.159. For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 was amended recently to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. See 73 FR 23353 (Apr. 30, 2008). The notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability; a connection between the veteran's service and the disability; degree of disability; and the effective date of any award of benefits. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits is issued by the agency of original jurisdiction. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The veteran filed his claim for service connection for tremors of his left upper extremity and left lower extremity in January 2003. In a letter dated in May 2003, the Honolulu RO notified the veteran of the evidence needed to substantiate his service connection claims. The RO told the veteran what evidence VA would obtain and what evidence he should provide and emphasized it was the veteran's responsibility to make sure VA received all requested records that were not in the possession of a Federal department or agency. In its October 2003 rating decision, the RO granted service connection for undiagnosed illness manifested by tremor in the left upper extremity and left lower extremity and assigned a 30 percent rating effective the date of receipt of the veteran's service connection claim in January 2003. As explained in the Introduction, the veteran's disagreement with the initial rating led to this appeal. During the course of the appeal, the RO redefined the service-connected disability as Parkinson's disease and assigned separate ratings for various extremities effective from December 2006. The United States Court of Appeals for Veterans Claims (Court) has held that in case where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated - it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 491. The Board therefore finds that notice requirements have been met as to the claims decided here. With regard to increased evaluation claims, the Court has found that, at a minimum, adequate section 5103(a) notice requires that VA notify the claimant that to substantiate an increased rating claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increased in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) 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; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Although this case involves consideration of initial ratings as opposed to increased ratings, the Board observes that in a letter dated in March 2006, the Honolulu RO discussed the assignment of disability ratings and effective dates, and in a letter dated in July 2008, the Reno RO also provided information about the evidence VA needs to make a decision regarding increased ratings. In both letters, it was explained that depending on the disability involved, VA assigns a rating from 0 percent to as much as 100 percent and that VA uses a schedule for evaluating disabilities that is published as title 38 Code of Federal Regulations, Part 4. The letters explained that in determining the disability rating VA considers evidence of the nature and symptoms of the condition, severity and duration of the symptoms, and impact of the condition and its symptoms on employment and daily life. The letters told the veteran that if he had any information or evidence that he had not previously told VA about or had not submitted, and that information or evidence concerned the level of his disability, he should submit it or tell VA about it. The letters stated that examples of evidence the veteran should identify included: information about on-going treatment records, including VA or other federal treatment records he had not previously told VA about; recent Social Security Administration determination; statement from employers as to job performance, lost time, or other information regarding how his condition affects his ability to work; or statements discussing his disability symptoms from people who have witnessed how they affect him. The letters reiterated that VA would get any federal records he told VA about and that while he was responsible for getting any private records he identified, VA would try to help him if he requested assistance. The March 2006 letter also described the kind of evidence considered in determining an effective date and provided examples of the evidence the veteran should identify or provide. The July 2008 letter set forth the rating criteria for paralysis agitans and for diseases of the peripheral nerves. The veteran had the opportunity to respond to all this information, there was subsequent readjudication by the Reno RO, and the Reno RO issued a supplemental statement of the case in August 2008. Moreover, the veteran had representation throughout the adjudication of his claims, which is a factor that may be considered by the Board. See Overton v. Nicholson, 20 Vet. App. 427, 438. Based on the foregoing, the Board finds that a reasonable person would have understood from the information that VA provided to the veteran what was necessary to substantiate higher ratings and concludes that he had a meaningful opportunity to participate in the adjudication of his case such that the essential fairness of the adjudication was not affected. See Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007). As to the duty to assist, the veteran's service treatment records are in the claims file. The RO has obtained private medical records identified by the veteran as well as VA medical records he identified. In addition, the veteran underwent VA examinations in September 2003, July 2007, and July 2008. There is no indication in the record that the veteran has or knows of any other evidence pertaining to his appeal. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the veteran and no additional assistance or notification is required. The veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. Background In a letter dated in February 2002, the Chief of Neurology at Straub Clinic and Hospital, James W. Pearce, M.D., certified that the veteran had been under his professional care since November 1999 and that the veteran had been taking Inderal to control his essential tremor. In an office note dated in November 1999, Dr. Pearce noted that the veteran had been referred by another physician for evaluation of tremor that had been present in the hands since March 1999, and it was noted the history included the symptoms being mild, more on the left than the right upper extremity. On motor system examination, bulk, strength, and tone were normal throughout except for a very fine, what Dr. Pearce said appeared to be, essential tremor in the upper extremities. Reflexes were intact at 1+ in the upper and lower extremities, and sensation was intact throughout. The diagnostic impression was essential tremor, rule out thyroid dysfunction. At a visit in early December 1999, the veteran wanted to know whether he could take a medication for his tremors. Dr. Pearce prescribed Inderal, and at a visit in late December 1999, the veteran denied any new symptoms. In late January 2000, the veteran stated the Inderal was helping. The diagnostic impression was essential tremor, and the Inderal was continued. In March 2001, Dr. Pearce stated the veteran would be allowed to take the Inderal one or two times a day and said the veteran seemed to be controlled fairly well on this. At a visit to Straub Clinic in May 2002, Dr. Pearce noted the veteran's tremor was well controlled on Inderal but that the veteran reported breakthrough tremulousness in the left index finger that sometimes made his finger strike a key on a keyboard when did not intend to do so. Dr. Pearce suggested an increased dose of Inderal. In December 2002, the veteran reported he had had two episodes of numbness on his left side that were unexplained. He said his tremor was static and remained responsive to the Inderal. In an office note dated in January 2003, Dr. Pearce noted the veteran was now stating that he was having decreased strength on the left side as well as intermittent numbness on the left side. The veteran reported no facial symptoms with this. Dr. Pearce noted that an MRI (magnetic resonance imaging) study of the brain that was done in January 2003 had been negative. A week later, the veteran stated that most of his symptoms of weakness had resolved. Dr. Pearce noted that an MRI study of the neck was negative. The veteran was continued on Inderal. When Dr. Pearce saw the veteran in July 2003, it was noted he had a history of increasing and then decreasing episodes of numbness that were transient in nature. The physician ordered an electroencephalogram (EEG), which was conducted in August 2003. The physician's interpretation was that it a normal EEG. At a follow-up clinic visit in August 2003, Dr. Pearce said there was no reason on either the MRI scan or EEG for the veteran's left arm numbness. Dr. Pearce noted that as of that visit the veteran reported the numbness seemed more localized to the left arm rather than the whole left side of his body. He ordered additional electromyography (EMG) and nerve conduction velocity studies of both upper extremities. When the veteran reported for the studies, it was noted that his chief complaint was that sometimes when he walked, his left leg dragged and his left leg was not working the way he wanted. Dr. Pearce said that upper extremity electromyography (EMG) nerve conduction studies in August 2003 were unremarkable. At a general physical examination conducted in August 2003 by Bradley K. Lee, M.D., at Straub Clinic, the veteran reported that for the last 4 to 5 years he had had a progressive weakness on the left upper and lower extremities. The veteran said that previously he had been able to run 3 to 4 miles a day, but now was only able to run a block or so before becoming fatigued. The physician said there was full range of motion of both upper and lower extremities. Deep tendon reflexes were 2+ out of 4+. The assessment included coarse tremor and history of left upper and lower extremity weakness. At a VA examination in September 2003, the veteran reported that the tremor on the left side of the body started in approximately 1993 while he was still on active duty. He said he had dismissed it and thought it was perhaps because he was drinking too much caffeine. The veteran said that since that time he had decreased his caffeine intake but that as time progressed, he had noticed that this tremor had increased in intensity and frequency. The veteran said his tremor was worse with activity and was worse in the upper extremity but would progress down into the lower extremity as well. The veteran said that in his current job as a police officer, was very distracting when his left hand, arm, fingers, and sometimes even his lower extremity began to shake uncontrollably with the tremor. He said it was difficult for him to type police reports because his left hand shakes so much that he continually miss-strikes the key and it takes much longer than it normally would or should. The veteran said that at home when he tries to drink a glass of water, he continually shakes from the beginning all the way up to his mouth. At the September 2003 VA examination, the veteran said that when he exercised in the past, he would drop the weights. He said he had reduced his exercise and that now after he exercised the twitch was so significant that it was almost like a whole body twitch and it would take hours for it to go away. He said he was so embarrassed that he had stopped exercising. He said he also used to take long walks, but the left leg seemed to want to quit and he had to tell his brain to tell his legs not to stop. The veteran said the tremor interfered with playing with his 8-year old child and made it difficult to lift his 1-year old child. He said the tremor prevented him doing household chores or yard work for extended periods and he had to do them in short spurts. The veteran reported that a year earlier he had passed the physical fitness test required at his work, but at this year's test his time in the mile and a half run had increased from 12 minutes to 16 minutes, where the maximum time allowed was 17 minutes. He said that this year he exceeded the time allowed for the 100 yard sprint and failed that part of the test. At the September 2003 VA examination, the physician said that deep tendon reflexes were hyperreflexic at 3/4 in the left lower extremity. Deep tendon reflexes were 2/4 in the right lower extremity and 2/4 in both upper extremities. The veteran had full range of motion in all extremities. The physician said that on intentional movements such as finger- to-nose and resistance strength testing, the tremor increased in severity. The physician said it was a fine intentional tremor. There was a significant tremor when the veteran's eyes were closed and his hands were extended in front of the body. Sensation was intact. Strength on hand grip was less in the left hand as opposed to the right hand. Gait was within normal limits. Records from Straub Clinic show that in February 2004 the veteran reported right-sided numbness and difficulty writing for two months. In a clinic note dated in February 2004 Dr. Pearce said that previous studies had shown nothing that would reveal an etiology for the veteran's weakness on the left side. In a note dated in early April 2004, Dr. Pearce said he thought the veteran was developing some clear extrapyramidal signs with paucity of facial expression, loss of some spontaneous movements, and slight change in gait. He noted that the veteran stated his writing had gotten smaller. Dr. Pearce said there was some questionable rigidity in the left upper extremity. He started the veteran on a trial of Sinemet. In a note dated in mid-April 2004, Dr. Pearce noted that the veteran had improved after a trial of Sinemet, therefore confirming early Parkinson's. He noted the veteran reported his tremor was decreased, his writing and improved, and his ambulation was better. Dr. Pearce said that on examination the veteran had much better associated movements with walking, and his gait was freer. He also said that the veteran's affect was improved. Dr. Pearce increased the Sinemet dosage. In a letter dated in April 2004, Dr. Pearce said that while the veteran had had some tremor for some time and this had gradually progressed over the years to show clinical signs of Parkinson's disease. Dr. Pearce said the veteran had been recently started on Sinemet. He said that at this point the veteran's Parkinson's disease would be considered mild to moderate and that many times Parkinson's disease is a progressive and a progressively disabling condition. In an office note dated in May 2004, Dr. Pearce said the veteran was better with Sinemet. He said he would increase the dose because the veteran still had some troubles with hemi-Parkinsonian symptoms. In late May 2004, the veteran said he noticed stiffness in his neck all the time. Dr. Pearce continued the veteran on the same medication. In August 2004, the veteran reported that he noticed spasms in different places and said he still had occasional stiffness in his neck and noticed tension in his neck. He said his walking was getting worse and he noticed his left foot was dragging. Dr. Pearce increased the Sinemet, added Klonopin and discontinued the Inderal. In September 2004, the veteran reported that the Klonopin was helping and he was not as stiff. He said he was still taking Inderal as needed. Dr. Pearce refilled the Sinemet and Klonopin. Records from Straub clinic show that in January 2005, the veteran said he had stiffness and the Sinemet was not working so well for him. Dr. Pearce indicated there had been confusion about the Sinemet dose, which he corrected. In March 2005, the veteran said he still had a stiff shoulder and reported increased shaking on the right side. Dr. Pearce commented that the veteran was currently quite stable and gave the veteran prescription refills for Klonopin and Sinemet. In a memorandum dated in July 2005, the veteran's police department work supervisor stated that employees were required to participate in a Fit for Life PT Test consisting of 30 push ups, 30 sit ups, bench press, shuttle run, 300 meter sprint, and a one and a half mile run. The supervisor stated that in June 2004 and June 2005 the veteran was unable to complete the push ups, the one and a half mile run, and the 300 meter sprint. The supervisor said that the veteran's medical condition could jeopardize his safety and the safety of his beat partners. In a statement dated in July 2005, a man who reported he worked with the veteran at the police department on a daily basis from April 2002 to January 2003 said that during that time he noticed the veteran's left hand an arm would shake while he was processing a prisoner. The fellow worker said that after January 2003 he had seen the veteran every two weeks and noticed the veteran walked with a limp on the left and his movement was slow and deliberate. In a July 2005 statement, another of the veteran's co-workers at the police department said that since about July 2004 he had noticed he veteran having tremors of the hand and also noticed that the veteran's left leg would shake on occasion. He said he had noticed the veteran's condition had been worsening and said that because of this he sometimes had to help the veteran with fingerprinting prisoners. He said he had recently noticed that the veteran had been walking with a limp on the left side and also appeared to be moving like a man older than his age. In a letter dated in July 2005 the veteran's wife said that she and the veteran had been married for nine years and that in the past five years she had noticed a big difference in his health. She said that at first she noticed that his left side (arm, hand, finger, and leg) would shake or tremble while he was just standing or sitting. She said that then she noted that when he picked things up his left arm would shake as if he was struggling with it. She said that now when they go for walk, it is for only a short distance because the veteran starts limping on his whole left side; she said his foot droops and starts to drag as he walks and his left arm appears not to swing along with his right. In a letter dated in August 2005, Dr. Pearce said the veteran had been under his care for a number of years for tremor and in the past couple of years this had manifested itself more clearly as Parkinson's disease with not only tremor, but stiffness on the left side, which produces a significant disability. In a statement dated in August 2005, a fellow serviceman reported he had known the veteran since 1991 when the served together in the Marine Corps. He recalled instances in service when he noticed shaking of the veteran's left arm. He remembered discussing it with the veteran who attributed it to drinking too much coffee. He said the veteran's left arm wound shake after a workout and although he advised the veteran to go to sick call, the veteran declined to do so. The fellow service man said he now occasionally saw the veteran at the police station and noted that the veteran did not seem to swing his left arm when he walked and did not move very smoothly. He noted that the veteran told him he had been unable to complete motorcycle training because he had a hard time manipulating the clutch. He said the veteran also told him that his shaking/tremors were getting to the point that he was using his sick leave because he did not want his coworkers to notice. In a letter dated in January 2006, Dr. Pearce said he had reviewed with the veteran his symptoms of stiffness and discomfort he had had for many years, dating back to when he was on active duty. This was primarily on the left upper extremity. Dr. Pearce said that considering the fact that the veteran now has Parkinson's disease, he would consider this an early sign of this disturbance. He said it probably did occur, but in an unrecognized fashion, during the time the veteran was on active duty. Dr. Pearce said it is common to have some symptoms of Parkinson's disease precede the actual diagnosis by years. At a VA primary care clinic visit in January 2006, the physician reviewed the veteran's history and noted that he had had to quit his job at the police department because of increasing tremors and because he was having difficulty with physical requirements. The history included having been diagnosed with Parkinson's disease in 2003, and it was noted that medications mitigated but did not suppress the veteran's symptoms. The veteran noted that his equilibrium was somewhat off and that he tended to drag his left foot and stumble. He reported that he occasionally had some dysphagia associated with swallowing liquids. No examination was done, and he was referred to the VA neurology clinic. At a VA neurology clinic visit in April 2006, the veteran reported that in addition to his tremors, he had been having involuntary twitching twice a day and when walking, stops/pauses before turning corners. The examiner noted resting tremor and tremors with the arms held out, left greater than right. There was trembling of the lower facial muscles when the veteran smiled. Rigidity was greater on the left than the right. When writing, there was shaking of the hands as well as micrographia. The examiner described the veteran's Parkinson's disease as moderately controlled by current medications. Prmipexole was added to his medications. At a VA rheumatology clinic visit in late April 2006, it was noticed that the veteran had a resting tremor of the right hand. At a VA neurology clinic visit in June 2006, the examiner noted the veteran had poor posture with decreased arm swing on the left. There was finger to nose action tremor, bilaterally. Rapid alternating movements were slow, worse on the left. There was lower tandem sway. At another visit later in June 2006, the physician noted that no dystonia or dyskinesias had been seen. The veteran was ordered to active duty from July 2006 to December 2006. Service treatment records show that in August 2006 it was reported that the veteran was observed shaking constantly while on the live firing line with a loaded weapon. The veteran reported he was on medications and gave a history of tremors since return from the Gulf War. The examiner noted chronic tremors while taking the veteran's pulse. He had good hand grip and resistance, good knee reflexes, and good bilateral foot pressure and resistance. The veteran's commanding officer recommended the veteran be issued a profile and that he not be deployed overseas. At a physical examination in service in September 2006, the veteran gave a history of paresthesias to the left arm intermittently, usually preceded by strenuous physical activity. He reported the symptoms persisted variable lengths of time, from 15 to 40 minutes. He said the worst episodes were accompanied by impaired motor ability. He gave history of constant chronic tremor of both upper extremities, left worse than right, and worse with intention. On examination, there was mild left arm weakness on strength testing against resistance to flexion and extension. Lower extremity reflexes were hyperreflexic at 3+/4, bilaterally. There were tremors, bilaterally, in the upper extremities, which the examiner said were mild secondary to medications. At a neurology consultation in service in September 2006, the physician noted mild high frequency, low amplitude, tremor of the outstretched extremities. He said there was no appreciable resting tremor, no bradykinesia, or muscular rigidity. He said the tremor was inconsistent at times. He said there was no evidence of micrographia, and blink rate and facial expressions were normal. The diagnosis after examination was enhanced physiologic tremor. The physician noted that the veteran was witnessed to have uncontrollable shaking of the upper limbs and eventually the entire body during a range exercise, where he was considered unfit to fire a weapon due to this problem. It was noted he had been tried on several medications to include clonazepam and Topamak for his tremors, but this had been ineffective for him. The physician recommended that the veteran be referred to the physical evaluation board for further disposition. In a September 2006 memorandum to the Medical Evaluation Board, the veteran stated that when he walked long distances his left foot drooped, and he said he had stumbled numerous times while walking up stairs. He also said that on three occasions he had fallen down on the stairs. He said that toward the end of the day he walked with a slight limp on the left side and does not swing his left arm while walking. He said that if he stood for a long period he could feel his legs trembling and the trembling eventually caused his whole body to tremble like a leaf in the wind. He said that he had also lost his balance while standing and that his handwriting had also been affected by his tremors, making it illegible by the end of a day. A November 2006 report of Physical Evaluation Board Proceedings describes the veteran's disability as enhanced physiologic tremor and noted that examination showed high frequency low amplitude tremor of outstretched extremities, inconsistent at times, without resting tremor or bradykinesia. It was stated that handwriting, coordination, and gait were normal. The report states that the veteran's functional limitations in maintaining the appropriate level of stamina, caused by these impairments, made the veteran medically unfit to perform his military duties. At a VA primary care clinic visit in January 2007, the physician noted tremors of both hands, more on the right. The veteran reported problems using a fork or chop sticks. At a VA neurology clinic visit in April 2007, the veteran reported that his tremors seemed to occur 95 percent of the time with movement, and rarely at rest. The veteran complained of numbness of both hands along the inner part of the arm, from the pinky up to the elbows. He said this started about two months ago and seemed to occur when his elbows are bent. He said his walking was okay for a short distance, but after one to two blocks, his left leg starts to drag. The veteran said his muscles seemed to twitch when he exercised. The physician noted possible mild mask facies. There was mild generalized bradykinesia. Sensation was within normal limits except for possible mild decreased pin prick along the ulnar aspect to the left hand, sparing the forearm and fingers. There was mild Tinel's over the ulnar wrist area, bilaterally, and over the ulnar elbow area on the left. There was questionable Tinel's over the left carpal tunnel area. Deep tendon reflexes of the arms were 4/4 biceps, and 1/4 brachioradialis and triceps. Deep tendon reflexes of the legs were 2+/4 knees, and 2/4 ankles. Reflexes of the toes were equivocal. The veteran was noted to have mild stooped posture. His regular gait was slow, but when he was in a hurry, the veteran seemed to be able to speed up and walk quite fast. The physician noted very mild positional tremor, bilaterally, in the arms. The veteran's handwriting was very small, though legible. There was mild cogwheeling in the elbows and questionably in the wrists. The impression after examination at the April 2007 VA neurology clinic visit was Parkinsonism and possible superimposed essential tremor. The physician noted that per his history the veteran has breakthrough tremors a few hours after taking his medication. The impression also included increased twitching of the extremity muscles with exercise, which the physician said was perhaps related to medication. The impression also included brisk reflexes mainly of the lower extremities, and the physician said the cause was not definite. In addition, the impression included intermittent numbness along the ulnar aspect of the hands and forearms, bilaterally, which the physician said was possible nerve irritation. At a VA neurology clinic visit in June 2007, the veteran reported he still had intermittent numbness of both upper extremities along the ulnar aspect. He reported continuing tremors for which he took medication and said he was also aware that he has irregular movements of his neck and extremities when sitting or even with standing. Regarding the veteran's gait, the physician note mild bradykinesia. He said the veteran had very mild positional tremor, bilaterally, in the arms. He said there was mild cogwheeling in the elbows and questionable in the wrists. He also said there was mild akisthesisa. The physician recommended modification of medications. At a VA neurology examination in July 2007, the veteran reported that his tremors are aggravated whenever he gets excited, becomes anxious, or does physical activity. He said he is unable to write when the tremors are severe, which happens 3 out of 5 working days. He said that on the weekends he considered himself fair, with mild to moderate exacerbations. He said that when the tremors were worse in his hand, it radiated to his extremities and to his whole body. He said that during the normal work week he tries to calm down so that the tremors will not worsen. It was noted that the veteran has akisthesia as a side effect of medication. At the July 2007 VA neurology examination, the veteran reported that he was currently working in security 10 hours a day, 4 days a week. He said he was required to walk, but avoided too much walking because this stiffened his left leg. He said this job was less stressful than his previous police work, and although he had taken off 3 to 4 days a month from his police job because of his symptoms, he had not taken off from his current job because it was not too stressful. The veteran said that at home he gets worsening tremors when he does strenuous physical activity. He reported he had lost fine motor skills and cannot manipulate any type of machinery, and cannot write legibly. He said that despite his medication, tremors are present all day if he gets an exacerbation. He said that his food falls off of his fork because of the tremors. He also reported he needed assistance from his wife when dressing, especially with fastening buttons on his shirt or zippers on his pants. He reported he is able to shave with an electric razor and was able to use the toilet and shower by himself. In an addendum report dated in late July 2007, the physician said the veteran has worsening symptoms of Parkinson's disease and as a result of resting tremors, which had become severe, he was unable to write legibly most days of the week. The physician also noted stiffness of the lower extremities and episodes of akisthesia because of the medications. The physician said that Parkinson's disease symptoms are mostly manifested with body stiffness and gait problems. He noted that the veteran had mentioned that in the past month his salary had been decreased and that his employer had become aware of the condition. At a VA general medical examination in July 2007, the examiner noted brisk tendon reflexes on the lower extremities. There was very mild akathesia. The examiner noted smooth cogwheel rigidity on both upper extremities. Fine resting tremors were noted on both arms and hands, and this was also noted upon movement of both arms. At a VA neurology clinic visit in August 2007, the veteran reported that when he reduced his Clonazepam dose, his tremors became worse, especially at work. He reported some stiffening of his right side occasionally, though he said that in general he felt the constant irregular movements had improved with the lower dose of Mirapex. He reported he still has occasional numbness of the hands, but only if he rested his elbow on a hard surface. He said his left leg sometimes gave out, particularly while going downstairs at work. He said this had been a problem for years, but was a little worse lately. On examination, the physician noted minimal bradykinesia. There was very mild positional tremor, bilaterally, in the arms. Standing on his toes, there was a rapid tremor in the legs. There was no definite weakness in the legs. There was generalized mild akisthesia. The physician recommended additional modifications to the veteran's medications. At a VA neurology clinic visit in October 2007, the physician said that regarding the veteran's gait, there was minimal bradykinesia. There were low amplitude positional tremors, bilaterally, in the hands. There was mild cogwheeling in the wrists and elbows. There was generalized mild akisthesia. The physician stated there was neck dystonia, and the veteran's head turned frequently to the left. The impression was Parkinsonism and possible superimposed essential tremor. The physician noted that per the veteran's history, he has breakthrough tremors if he takes Mirapex and Sinemet fewer than 4 times a day and often with the 4 times a day dose. The impression also included low-frequency tremor of the hands, which the physician said was perhaps due to medication side effect. The physician said the cause of brisk reflexes mainly of the lower extremities was not definite. The impression also included intermittent numbness along the ulnar aspect of the hands and forearms, bilaterally, which the physician said was probable ulnar nerve irritation. The physician said that tightness and soreness of the trapezius muscles, bilaterally, was possible due in part to the dystonia of the neck. The physician noted the veteran occasionally felt the left leg giving out, and the physician said question if this is from a dyskinetic movement. The physician adjusted the veteran's medications. He recommended a neurosurgery consultation to consider deep brain stimulation. At a VA neurology clinic visit in January 2008, it was noted that examination was similar to October 2007 except there was a decrease in akisthesia and dystonia. At a VA neurology consultation visit in February 2008, it was noted that in 2003 the veteran had been diagnosed as having Parkinson's disease. The veteran reported that his first symptom was left hand tremor, which was predominantly resting, and the symptoms progressed to include his right hand. He also reported that he developed stiffness and slowness, mainly on the left side. At the visit, the veteran complained of balance problems, but said he had not fallen recently. He said he occasionally suffered from freezing gait. He also said he occasionally had swallowing problems and once in a while choked on food. The veteran reported dyskinesias for at least three years that affects the upper part of his body. He complained of neck pains and radiation to both shoulders. On examination, deep tendon reflexes were 2+ at biceps, and 3+ at the knees and ankles. The veteran's gait showed slightly stooped posture with bradykinesia, left, and slow turning. There was mildly impaired left sided finger tapping/rapid alternating movement, hand opening, and hand closing. The physician adjusted the veteran's medication. It was noted that the veteran was aware of deep brain stimulation and was not interested. At a VA neurology clinic visit in June 2008, examination revealed mild akisthesia of the upper extremities and trunk. Regarding the veteran's gait, there was minimal bradykinesia. There was no twitching, and there were no tremors at rest. There was mild cogwheeling in the wrists and elbows. At a July 2008 VA fee-basis consultation for electrodiagnostic studies, it was noted that the veteran had a history of tremor of the arms, tremor of the legs, weakness of the left arm, and weakness of the left leg. He also had a history of dragging his left foot with walking. On clinical examination, the physician noted a 10-Hertz Parkinsonian tremor of the upper extremities. The physician performed electromyography (EMG) studies of muscle groups of both upper extremities, both lower extremities, and paraspinal muscles, which he said revealed normal insertional resting and exertional potential. The physician stated that he found no evidence of neuropathy, myopathy, or radiculopathy. He said the veteran does have clinical evidence consistent with Parkinson's disease and has a 10-Hertz Parkinsonian tremor of both upper extremities. He said the tremors of the upper extremities, particularly the hand, affect the veteran's grip and are causing continuous moderate disability. The physician said that weakness of the left leg after walking one to two blocks and the dragging of the left foot are due to the Parkinson's disease. He said the weakness is not due to the veteran's fibromyalgia. In August 2008, the veteran submitted an October 2003 Internet article from American Family Physician on the topic of tremors. Analysis Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. 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. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. When an unlisted condition is encountered, it is permissible to rate it under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2008). Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis or for those not fully supported by clinical and laboratory findings. Id. The determination of whether an increased evaluation is warranted is to be based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1, which requires that each disability be viewed in relation to its history. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In deciding the veteran's claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007) and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the Court held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126. Hart appears to extend Fenderson to all increased evaluation claims. As outlined in the Introduction, the RO has rated the veteran's Parkinson's disease as 30 percent disabling from January 2003 to July 2006 under Diagnostic Code 8004 for paralysis agitans. 38 C.F.R. § 4.124a, Diagnostic Code 8004. Paralysis agitans is also known as Parkinson's disease. Dorland's Illustrated Medical Dictionary 972 (26th ed. 1990). The RO discontinued the 30 percent rating in July 2006 when the veteran returned to active duty and assigned separate ratings for each of the veteran's upper extremities and for his left lower extremity effective the day following his discharge from service in December 2006. The veteran has disagreed with all of these initial ratings. Evaluations of neurological conditions and their residuals may be rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. Psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc. are to be considered. With partial loss of use of one or more extremities from neurological lesions, diseases and residuals are to be rated by comparison with mild, moderate, severe, or complete paralysis of peripheral nerves. 38 C.F.R. § 4.124a. When it has assigned separate ratings for various extremities, the RO has rated neurological impairment of the upper extremities under Diagnostic Code 8515, which pertains to impairment of the median nerve. It has rated neurological impairment of the left lower extremity under Diagnostic Code 8520, which pertains to impairment of the sciatic nerve. Diagnostic Code 8515 provides a 70 percent rating for the major extremity and a 60 percent disability rating for the minor extremity if there is complete paralysis of the median nerve. The factors indicative of complete paralysis consist of the hand inclined to the ulnar side; the index and middle fingers more extended than normally; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); incomplete and defective pronation; absence of flexion of the index finger and feeble flexion of the middle finger; inability to make a fist; index and middle fingers remain extended; inability to flex the distal phalanx of the thumb; defective opposition and abduction of the thumb, at right angles to the palm; flexion of the wrist weakened; pain with trophic disturbances. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. If paralysis is incomplete, Diagnostic Code 8515 provides a 50 percent rating for severe disability in the major extremity and a 40 percent rating for severe disability in the minor extremity. For moderate incomplete paralysis, a 30 percent rating is warranted for the major extremity and a 20 percent rating is warranted for the minor extremity; a 10 percent rating is warranted for mild incomplete paralysis of the major extremity and for mild incomplete paralysis of the minor extremity. Id. Under Diagnostic Code 8520, incomplete paralysis of the sciatic nerve is rated 10 percent when mild, 20 percent when moderate, 40 percent when moderately severe, and 60 percent when severe with marked muscular atrophy. 38 C.F.R. § 4.124a; Diagnostic Code 8520. An 80 percent rating is warranted for complete paralysis of the sciatic nerve, wherein the foot dangles and drops, no active movement of muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. Id. The words "moderate" and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2008). The Board observes that "moderate" is generally defined as "of average or medium quality, amount, scope, range, etc." See Webster's New World Dictionary, Third College Edition, 871. "Severe" is generally defined as "of a great degree: serious." See Webster's Ninth New Collegiate Dictionary (1990), 1078. The term "incomplete paralysis" as it pertains to peripheral nerve disabilities indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. In this case, from the beginning of the rating period, which dates from January 2003, the evidence shows that the veteran has experienced tremors of both upper extremities which equates to mild incomplete paralysis under Diagnostic Code 8515. The record further shows that as to the left upper extremity, which is the veteran's minor extremity, examiners noted decreased grip strength on the left along with some rigidity in the left upper extremity, and the veteran's wife and friends have made statements attesting to the pronounced shaking of the veteran's left arm. In addition, Dr. Pearce, the veteran's private neurologist at Straub clinic, noted some change in gait, and the veteran's wife and friends as well as the veteran reported the veteran walked with a limp on the left, and the veteran's wife confirmed the veteran's reports that his left foot started to drag when he walked more than a short distance. In this regard, in an August 2005 letter, Dr Pearce said the veteran had been under his care for a number of years for tremor and in the past couple of years this had manifested itself more clearly as Parkinson's disease with not only tremor, but stiffness on the left side, which produces a significant disability. By April 2006, at a VA neurology clinic visit the veteran reported that in addition to his tremors he had been having involuntary twitching, and the examiner noted tremors of the upper extremities, left greater than right, and rigidity, greater on the left than the right. The examiner described the veteran's Parkinson's disease as moderately controlled by current medication. Based on this the Board finds that from January 2003 to July 2006, rather than rating the veteran's Parkinson's disease as 30 percent disabling under Diagnostic Code 8004, the minimum rating for paralysis agitans, it is more advantageous to the veteran to rate the manifestations of the disease separately. In the Board's judgment, the evidence, which shows tremor of the right upper extremity, supports a 10 percent rating for the right upper extremity rated as mild incomplete paralysis of the median nerve of the major upper extremity. The next higher rating of 20 percent is not met, however, because during the period, there was no showing of functional impairment of the right upper extremity in terms of loss of strength or coordination. The Board acknowledges that micrographia was noted by the end of the period, but it was not until later that there is evidence of illegibility of the veteran's writing or interference with fine motor skills needed for dressing. From January 2003 to July 2006, manifestations of the veteran's Parkinson's disease as it affected his left upper extremity included not only tremors but also some rigidity and diminution of strength. Further, the totality of the evidence indicates that it was due primarily to the veteran's increasing tremors and difficulty with physical requirements during that period that near the end of the period the veteran had to quit his police department job, which he later replaced with a less stressful job as a job as a security guard. Statements from co-workers, the veteran's wife, and the veteran himself emphasize the veteran's problems with the left upper extremity. The Board therefore finds that for the period the degree of disability of the left upper extremity may be rated as moderate incomplete paralysis of the median nerve, which warrants a 20 percent rating. This accounts for shaking of the left upper extremity, which reportedly interfered with the veteran's duties including typing reports and fingerprinting prisoners while he worked for the police department. The evidence does not, however, support the next higher 40 percent rating for this period for the left upper extremity because there is no evidence of actual paralysis, muscle atrophy, of other symptoms that can be regarded as equivalent to severe incomplete paralysis of the median nerve. From January 2003 to July 2006, manifestations of the veteran's Parkinson's disease as it affected his left lower extremity included change of gait noted by examiners, and the veteran's friends, wife, and the veteran himself reporting trembling in the left lower extremity as well as a left limp. In addition, the veteran and his wife reported that when he walked more than a short distance, his left foot would drag, and during the period the veteran's ability to perform physical fitness tests involving running declined to the point that he failed certain tests. Although VA physicians have expressed doubt as to the etiology of hyperreflexic reflexes in the lower extremities, it was noted that there was some improvement in ambulation after the veteran was given a trial of Sinemet, which along with some improvement of other symptoms was said to confirm Parkinson's disease. The Board therefore finds that for the period from January 2003 to July 2006 manifestations of the veteran's Parkinson's disease as it affected his left lower extremity resulted in disability equivalent to moderate incomplete paralysis of the sciatic nerve, which warrants a 20 percent rating. There was, however, no clinical finding of any atrophy of the musculature of the left lower extremity or any other evidence indicative of functional loss indicative of disability equivalent to moderately severe incomplete paralysis of the sciatic nerve, which would be required for the next higher 40 percent rating. Effective from December 2, 2006, the RO assigned a 30 percent rating for Parkinson's disease tremors of the right upper extremity under Diagnostic Code 8515 for the major upper extremity, a 20 percent rating for Parkinson's disease tremors of the left upper extremity under Diagnostic Code 8515 for the minor upper extremity, and a 20 percent rating for Parkinson's disease bradykinesia and weakness of the left lower extremity under Diagnostic Code 8520. The Board must decide entitlement to higher initial ratings. As to the right upper extremity, review of the evidence shows that from December 2006, manifestations of the veteran's Parkinson's disease as it affects his right upper extremity (his major upper extremity) include tremor, some cogwheel rigidly at the elbow and wrist, intermittent inability to write legibly or hold food on a fork when his tremors are severe along with difficulty fastening buttons and using zippers. This, in the Board's judgment is equivalent to severe incomplete paralysis of the median nerve, which warrants a 50 percent rating. The disability does not, however, meet or approximate the criteria for the next higher 70 percent rating, which is reserved for complete paralysis of the median nerve involving considerable muscle atrophy and limitation of motion of the thumb and fingers. The evidence does not demonstrate this sort of impairment, and the preponderance of the evidence is against an initial rating in excess of 50 percent for disability of the right upper extremity manifestations of Parkinson's disease from December 2, 2006. For the left upper extremity manifestations of Parkinson's disease from December 2, 2006, the evidence shows tremors, weakness, cogwheel rigidity at the elbow and wrist, and difficulty with fine motor skills. This, in the Board's judgment, reflects a continuation of a degree of functional impairment of the minor upper extremity equivalent to moderate incomplete paralysis of the median nerve, warranting no more than the currently assigned 20 percent rating. The evidence from December 2006 forward does not indicate substantial worsening of the left upper extremity symptoms, and there is no evidence of actual paralysis, muscle atrophy, or other symptoms that can be regarded as equivalent to severe incomplete paralysis of the median nerve of the minor upper extremity, which would be required for the assignment of the next higher 40 percent rating. Reviewing the evidence from December 2006 forward shows the veteran continued to report left lower extremity symptoms including stiffness of the left leg and weakness of the left leg with dragging of the left foot after walking one to two blocks. The veteran has also reported balance problems with stumbling and has stated he occasionally suffers from freezing gait. In this regard, at a VA neurology consultation in February 2008, the veteran's gait showed slightly stooped posture with bradykinesia, left, and slow turning. Thus, overall, the Board finds that from December 2, 2006, manifestations of the veteran's Parkinson's disease as it affects his left lower extremity include stooped posture, occasionally freezing gait, some bradykinesia, stiffness, and weakness of the left leg with left foot dragging after walking more than short distances. In combination, and with and with resolution of reasonable doubt in favor of the veteran, the Board finds that the manifestations approximate moderately severe incomplete paralysis of the sciatic nerve, which warrants a 40 percent rating under Diagnostic Code 8520. The Board finds no evidence of atrophy, let alone marked atrophy, of the muscles of the left lower extremity or functional impairment that suggests severe incomplete paralysis of the sciatic nerve, which would be required for the next higher 60 percent rating. In addition to the foregoing, the Board notes that starting with the July 2007 VA neurology examination, in an addendum report, the physician noted stiffness of both lower extremities because of medications for Parkinson's disease. Also, at a VA neurology clinic visit in August 2007, the veteran reported stiffening of his right side occasionally. On examination, when standing on his toes there was a rapid tremor in the legs. Although the inclusion of both lower extremities in these findings indicates the presence of symptoms in the right lower extremity, the tremors in the right leg were found only while the veteran was standing on his toes, and the veteran himself said that the stiffness on the right was only occasional. This does not warrant a separate compensable rating for right lower extremity manifestations of Parkinson's disease. There is no showing of more than minimal functional impairment of the right lower extremity, and in the Board's judgment, it cannot be found that there is disability of the right lower extremity equivalent to mild incomplete paralysis of the sciatic nerve, which would be required for a 10 percent rating under Diagnostic Code 8520. The Board is also aware that the evidence shows that from December 2006, there have been findings of neck dystonia, with the veteran's head turning frequently to the left as well as generalized mild akisthesia, both associated with medications for the veteran's Parkinson's disease. Further, the record shows that in its December 2007rating decision the Reno granted service connection for dystonia but did not assign a separate rating stating it was determined to be part and parcel of the evaluation for Parkinson's disease. There is no indication in the record before the Board that the veteran filed a notice of disagreement with that determination, but in view of the assignment of separate ratings for various manifestations of the veteran's Parkinson's disease, the Board will discuss whether a separate rating is warranted for dystonia and akisthesia. The VA Rating Schedule does not specifically address akisthesia, which is a feeling of internal restlessness, but it does provide diagnostic code suitable for rating dystonia and which, by analogy, might be used for rating akisthesia. That code is Diagnostic Code 8103 for convulsive tic. The evaluation for convulsive tic depends upon the frequency and severity of attacks and the muscle groups involved. A noncompensable evaluation is warranted when the disorder is mild, a 10 percent rating is warranted when the disorder is moderate, and a maximum 30 percent rating is warranted when the disorder is severe. 38 C.F.R. § 4.124a, Diagnostic Code 8103. In this case, examiners have consistently described the veteran's generalized akisthesia as mild, and the dystonia has been primarily associated with the neck. The veteran has reported pain radiating to the trapezius area, and he has associated this with his service-connected fibromyalgia. In this regard, review of the record confirms that service connection is in effect for fibromyalgia, and that tender points at the borders of the trapezius muscles and the borders of the scapulae have been considered in the assigned rating. According to 38 C.F.R. § 4.14, the evaluation of the same disability under different diagnoses is to be avoided, and the Board will therefore not include muscle impairment of the neck and trapezius area in its consideration of whether there may be a separate compensable rating assigned for the veteran's dystonia and akisthesia associated with medications for his service-connected Parkinson's disease. Although the veteran reported at a VA neurology visit in June 2007 that he had been aware of irregular movements of his neck and extremities and a VA physician in October 2007 noted neck dystonia, with the veteran's head turning frequently to the left, there is nothing in the record to suggest there are more than mild symptoms associated with the dystonia and akisthesia. The veteran has not reported that the symptoms interfere with daily activities or employment, and there is no basis to find that the symptoms meet or approximate moderate impairment, which is required for the assignment of a compensable rating. In summary, the Board has found that prior to July 4, 2006, it is more advantageous to the veteran to rate the manifestations of his Parkinson's disease separately rather to continue the 30 percent rating assigned by the RO under Diagnostic Code 8004. The result is that the Board has concluded that prior to July 4, 2004, the evidence supports an initial 10 percent rating for the right (major) upper extremity, an initial 20 percent rating for the left (minor) upper extremity, and an initial 20 percent rating for the left lower extremity. As to initial ratings from December 2, 2006, after the veteran was discharged from a period of active service, the Board has concluded that the evidence supports an initial 50 percent rating for the right (major) upper extremity. The Board has further concluded that from December 2, 2006, the evidence does not support an initial rating in excess of the currently assigned 20 percent for the left upper extremity, nor does it support an initial rating in excess of the currently assigned 20 percent rating for the left lower extremity. The Board considered the possibility of separate compensable ratings for the right lower extremity and for dystonia and akisthesia associated with prescribed medications, but concluded that associated symptoms are not of sufficient severity as to warrant compensable ratings. (CONTINUED ON NEXT PAGE) ORDER An initial 10 percent rating for manifestations of the veteran's Parkinson's disease as it affected his right (major) upper extremity prior to July 4, 2006, is granted subject to the law and regulations regarding the payment of monetary benefits. An initial 20 percent rating for manifestations of the veteran's Parkinson's disease as it affected his left (minor) upper extremity prior to July 4, 2006, is granted subject to the law and regulations regarding the payment of monetary benefits. An initial 20 percent rating for manifestations of the veteran's Parkinson's disease as it affected his left lower extremity prior to July 4, 2006, is granted subject to the law and regulations regarding the payment of monetary benefits. An initial 50 percent rating for manifestations of the veteran's Parkinson's disease as it has affected his right (major) upper extremity is granted from December 2, 2006, subject to the law and regulations regarding the payment of monetary benefits. An initial rating in excess of 20 percent for manifestations of the veteran's Parkinson's disease as it has affected his left (minor) upper extremity from December 2, 2006, is denied. An initial 40 percent rating for manifestations of the veteran's Parkinson's disease as it has affected his left lower extremity is granted from December 2, 2006, subject to the law and regulations regarding the payment of monetary benefits. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs