Citation Nr: 1032829 Decision Date: 08/31/10 Archive Date: 09/08/10 DOCKET NO. 98-18 997 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a variously diagnosed psychiatric disorder, including post-traumatic stress disorder (PTSD) and depressive reaction. 2. Entitlement to service connection for headaches, diarrhea, hair loss, fatigue, a sleep disorder, and for joint and muscle pain, all due to an undiagnosed illness. 3. Entitlement to an initial rating in excess of 10 percent for low back strain prior to December 21, 2006 and to an initial rating in excess of 20 percent from that date. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from September 1980 to September 1984, from November 1990 to September 1991, and from March 1992 to September 1992. These matters come before the Board of Veterans' Appeals (BVA or Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey, which denied the benefits sought on appeal. In a December 1997 rating decision, the RO granted service connection for a low back strain and assigned a 10 percent rating effective November 22, 1996. In a January 2007 rating decision, the RO increased the assigned rating to 20 percent disabling, effective December 21, 2006. The Board notes that the rating decisions have essentially resulted in staged ratings for low back strain. In June 2007, the Veteran testified at a Travel Board hearing before the undersigned; a transcript of that hearing is of record. The appellant submitted additional medical evidence along with a waiver of consideration by the agency of original jurisdiction. FINDINGS OF FACT 1. The Veteran served in Southwest Asia from January 1991 to July 1991. 2. The Veteran's lay testimony regarding being separated from his convoy and lost without communication, being located 50 yards from explosions, having air fights going on around him, seeing numerous dead bodies, fearing for his life, and seeing makeshift graves, pillboxes, gravesites and unexploded ordinances is credible, consistent with the places, dates, and circumstances of service in Southwest Asia, and is sufficient to verify the occurrence of the reported events. 3. There is medical evidence of record linking the Veteran's currently diagnosed PTSD to a verified in-service stressor. 4. The Veteran's PTSD encompasses manifestations of depressive reaction. 5. While the Veteran has complaints of headaches, diarrhea, hair loss, fatigue, and joint and muscle pain, the probative medical evidence does not relate such symptoms to the Veteran's service, or to an undiagnosed illness. 6. The Veteran's complaints of sleep disturbance/disorder have been attributed to his service-connected psychiatric disorder, including PTSD. 7. Throughout the appeal period, the Veteran's low back strain has been manifested in moderate limitation of motion; there is no evidence of severe loss of lumbar spine motion; forward flexion of the thoracolumbar spine limited to 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; 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 osteo- arthritic changes, or narrowing or irregularity of joint space, or abnormal mobility on forced motion; severe intervertebral disc syndrome with recurring attacks with intermittent relief; neurological symptoms warranting a separate compensable rating; or incapacitating episodes of intervertebral disc syndrome having a total duration of at least four weeks during the past year. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a variously diagnosed psychiatric disorder, including PTSD have been met. 38 U.S.C.A. §§ 1110, 1131, 1154 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 4.125 (2009), 75 Fed.Reg. 39,843 (Jul 13, 2010). 2. The criteria for service connection for headaches, diarrhea, hair loss, fatigue, joint and muscle pain, and sleep disturbance, to as due to undiagnosed illness or other qualifying chronic disability have not been met. 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2009). 3. Prior to December 21, 2006, the criteria for a 20 percent rating for low back strain have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Codes 5292, 5293, 5295 (prior to September 23, 2002); Code 5293 (from September 23, 2002 through September 25, 2003); Codes 5237, 5242, 5243 (from September 26, 2003). 4. From December 21, 200, the criteria for a rating in excess of 20 percent rating for low back strain have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Codes 5292, 5293, 5295 (prior to September 23, 2002); Code 5293 (from September 23, 2002 through September 25, 2003); Codes 5237, 5242, 5243 (from September 26, 2003). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). ; see Hickson, 12 Vet. App. at 253 (lay evidence of in- service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). A disorder may be service connected if the evidence of record, regardless of its date, shows that the Veteran had a chronic disorder in service or during an applicable presumptive period, and that the Veteran still has such a disorder. 38 C.F.R. § 303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). A. A Variously Diagnosed Psychiatric Disorder, including PTSD and Depressive Reaction Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV)); in certain circumstances, credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). Under DSM-IV, a stressor is a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others; and (2) the person's response involved intense fear, helplessness, or horror. A stressor must consist of an event during such service that is outside the range of usual human experience and such that would be markedly distressing to almost anyone, such as experiencing an immediate threat to one's life or witnessing another person being seriously injured or killed. It is the distressing event, not mere presence, that constitutes a valid stressor. Zarycki v. Brown, 6 Vet. App. 91, 99 (1994). Moreover, service in a combat zone is stressful to some degree to all who are there, whatever their duties or experiences. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see also VAOPGCPREC 12-99 (Oct. 18, 1999) (cited at 65 Fed. Reg. 6257 (2000)) ("the phrase 'engaged in combat with the enemy,' as used in 38 U.S.C. § 1154(b), requires that a veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality"). For claims that were appealed to the Board but not decided as of July 13, 2010, changes to the applicable regulations are in effect. Specifically, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f) (3); 75 Fed.Reg. 39,843 (Jul 13, 2010) "Fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The occurrence of an event alleged as the "stressor" upon which a PTSD diagnosis is based (as opposed to the sufficiency of the alleged event to cause PTSD) is an adjudicative determination, not a medical determination. Zarycki v. Brown, 6 Vet. App. 91, 97-98 (1993). In this case, service personnel records show that the Veteran served in Saudi Arabia from January 14, 1991 to July 25, 1991. His DD Form 214 reveals that he had service with the 1/158th Field Artillery Battalion as a power generator mechanic. The limited available service treatment records included an April 1994 report of medical history and clinical that was negative for complaints, treatment, or diagnoses relating to a psychiatric disorder. On his report of medical history, the Veteran specifically indicated that he did not have depression or excessive worry, or nervous trouble of any sort. VA treatment records showed that the Veteran sporadically received treatment from 1996 to 2007. A February 1998 record noted that the Veteran had felt depressed since his return from the Persian Gulf War. He was diagnosed with, among other things, probable PTSD. On May 1997 VA examination, the Veteran reported that he served in the Persian Gulf for six months. He served with A Battery, 1st Battalion, 158th Field Artillery. He indicated that he was in combat conditions. He reported that his unit came under fire by friendly forces who were firing at enemy tanks, resulting in the Veteran's unit being caught in the cross fire. There were close calls, but no causalities. He witnessed several enemy casualties. He indicated that he was also stressed by chemical alerts during which he was required to wear heavy, confining protective gear for up to two hours. The examiner noted that the Veteran experienced persistent and recurrent muscle pain and sleeping disturbances with secondary symptoms of anxiety and depression. The Veteran reported that he had feelings depression and anxiety secondary to his physical health problems and fear for his future. After examination, he was diagnosed with depressive reaction considered secondary to physical health problems and inability to work (since January 1996). A February 1998 initial evaluation by Rutgers Anxiety Disorders Clinic noted that the Veteran was experiencing a variety of emotional and physical difficulties since his return from the Gulf War in 1991. Additionally, several significant stressors occurred since his return from the Gulf, such as having a car accident, losing his job, and the death of his brother that exacerbated his symptoms. His psychological difficulties included, recurrent nightmares, sleeping difficulties, severe daily anxiety, intrusive flashbacks, weight loss, depressions, loss of interest in pleasurable activities, cognitive confusion, alcohol and drug abuse, and active suicidal ideation. He described several traumatic incidents such as being separated from his convoy and lost for several hours, being caught in friendly fire, having air fights around him, and seeing numerous dead bodies. He described several occasions where he felt as if he were going to lose his life, both during combat and air fights, and when he was almost accidentally shot by his own troops at night by mistake. He was voluntarily hospitalized in the VA Hospital in East Orange in February 1998. His diagnoses included major depressive disorder, alcohol and cocaine abuse, and PTSD. On October 1998 VA examination, the Veteran reported that he witnessed a vehicle detonate a land mine. He also was caught in the crossfire between enemy and British tanks on February 26, 1991, in which explosions occurred within 50 yards of his position. After examination, the Veteran was diagnosed with major depressive disorder, no psychosis, manifested by persistent depression, low self-esteem, lack of motivation for goal directed activities, and social isolation. He also had PTSD manifested by nightmares of Persian Gulf experiences, intrusive memories of combat and excessive startle reactions to loud sounds. His Axis IV diagnosis included, among other things, combat stress. His Global Assessment of Functioning (GAF) score was 45. In an August 2000 addendum, the VA examiner indicated that in reviewing the May 1997 and October 1998 VA examination reports, there was an implication that symptoms of depression and/or PTSD did not begin until after the Veteran's Persian Gulf experience in 1991. At his June 2007 Travel Board hearing, the Veteran reported that he once was separated from his unit for about an hour and as there was no radio in the vehicle there was no way of communicating. He also was part of a convoy, in which there were explosions going on around them. He saw makeshift graves, pillboxes, gravesites, and unexploded ordinances. He also indicated that he saw a private doctor at Rutgers that his VA representative hired. He stopped seeing the private doctor because he ended his relationship with that VA representative. The documents in the claims file, including a February 1998 initial evaluation by Rutgers Disorders Clinic, and October 1998 VA examination, satisfy the first element of a PTSD claim under the former and revised criteria of 38 C.F.R. § 3.304(f) because they include diagnoses of PTSD. The October 1998 VA examination also satisfies the second element of a PTSD claim under the former and revised criteria 38 C.F.R. § 3.304(f), because it links the Veteran's PTSD to combat stress and Persian Gulf War experiences and thus to in-service stressors, including being caught in the crossfire between enemy and British tanks on February 26, 1991 and that explosions that occurred within 50 yards of his position and witnessing a vehicle detonating a land mine. Having submitted a diagnosis of PTSD that is linked to claimed in-service traumatic stressors, the Board must now determine whether the record contains credible supporting evidence that the claimed in-service stressors actually occurred. A veteran need not corroborate every detail of an alleged stressor, including his participation in the activity, for verification purposes. Suozzi v. Brown, 10 Vet. App. 307, 311 (1997); Pentecost v. Principi, 16 Vet. App. 124, 128 (2002) (holding that a veteran who had a military occupational specialty unrelated to combat, but was stationed with a unit that sustained attacks strongly suggests that the veteran was, in fact, exposed to these attacks). In this case, the Veteran's DD Form 214 and other service personnel records establish that he served in the Saudi Arabia as a member of the A Battery 1/158th Field Artillery Battalion as a power generator mechanic. He received a Humanitarian Service Medal, National Defense Service Medal, Southwest Asia Service Medal, and the Desert Storm Service Medal. These particular records, which do not reflect that the Veteran was commended for combat or received a Combat Infantryman Badge or Purple Heart, which are awarded for combat-related circumstances, do not establish the Veteran's engagement in combat. Regardless, the Board concludes that service connection for PTSD is warranted under the new regulations permitting the Veteran's own statements to establish the occurrence of a stressor. The weight of credible medical evidence shows that he has been diagnosed with PTSD related to the events in Iraq as reported to VA examiners and adjudicators. Although the record does not show that the Veteran engaged in combat action, service personnel records showed that he served in a combat area in duties, places, and circumstances consistent with his reports of traumatic events that included being close to explosions that occurred within 50 yards of his position; being separated from his convoy and lost for several hours; having air fights around him; seeing numerous dead bodies; fearing for his life; and seeing makeshift graves, pillboxes, gravesites, and unexploded ordinances. The Board concludes that the Veteran's lay testimony of these events is consistent, credible, and sufficient to verify the occurrence of the events. Certainly there is no evidence of record to indicate otherwise. Therefore, service connection is warranted. The Board notes that in reaching this conclusion, the evidence is at least in equipoise, and the benefit of the doubt doctrine has been appropriately applied. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In regards to the Veteran's claim seeking service connection for depressive reaction, the Board finds that this claim is now moot because the Veteran has now been service-connected for PTSD that encompasses the manifestations of a depressive disorder. In an August 2000 addendum to a prior VA examination, the examiner noted the Veteran's PTSD and depression disorder encompassed dysphoric mood, irritability, social isolation, poor concentration, etc, even though his psychiatric implantology has been divided into two separate and distinct categories. Absent evidence of a mental disability with distinct symptomatology from his service-connected PTSD, consideration of service connection for a psychiatric disorder, claimed as depressive reaction, is not warranted. Such an action would amount to impermissible pyramiding. 38 C.F.R. § 4.14 (2009). VA is prohibited from awarding disability benefits for two separate diagnoses that produce the same manifestations of a disability. B. Service connection for headaches, diarrhea, hair loss, fatigue, a sleep disorder, and for joint and muscle pain, all due to an undiagnosed illness The Persian Gulf War Veterans' Benefits Act authorizes VA to compensate any Persian Gulf War Veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses that became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a specified presumption period following service in the Southwest Asia theater of operations during the Persian Gulf War. This statute expands the definition of "qualifying chronic disability" (for service connection) to include not only a disability resulting from an undiagnosed illness as stated in prior law, but also any diagnosed illness that the Secretary determines in regulations warrants a presumption of service connection under 38 U.S.C.A. § 1117(d). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). A "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of any of the following): an undiagnosed illness; a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms; and any diagnosed illness that the Secretary determines (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome). 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, fatigue, unexplained rashes or other dermatological signs or symptoms, headaches, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). There must be objective indications of chronic disability, and this includes "signs" in the medical sense of objective evidence perceptible to an examining physician and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). A disability is considered chronic if it has existed for six months or more, even if exhibiting intermittent episodes of improvement and worsening throughout that six-month period. 38 C.F.R. § 3.317(a)(4). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). At the outset, the Board finds that the grant of direct service connection or presumptive service connection under 38 C.F.R. § 3.317 is not possible for the Veteran's sleep disturbance. This is because the Veteran's sleep disturbance has been shown to be a symptom of a psychiatric disorder, including PTSD and Major Depressive Disorder. On February 1998 evaluation by Rutgers Anxiety Disorders clinic found that the Veteran's psychological difficulties included recurrent nightmares, and sleeping difficulties. Because the Veteran's sleep disturbance has been attributed to a known clinical diagnosis, entitlement to presumptive service connection under 38 C.F.R. § 3.317 is precluded. Service connection has been granted in this decision for PTSD and this symptom will considered when assigning the percent disability evaluation. The competent evidence of record does not show that the Veteran's sleep disturbance is causally related to active duty outside of his service-connected PTSD such as to enable a grant of service connection on a direct, nonpresumptive basis. In regards to the remaining issues, the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for headaches, diarrhea, hair loss, fatigue, and joint and muscle pain, including as due to an undiagnosed illness, so these claims must be denied. 38 C.F.R. § 3.102. The limited available service treatment records (STR's) included an April 1994 report of medical history and clinical evaluation that was negative for complaints, treatment, or diagnoses relating to headaches, diarrhea, hair loss, fatigue, and for joint and muscle pain, all due to an undiagnosed illness. On his report of medical history, the Veteran specifically indicated that he did not have swollen or painful joints, frequent or severe headache, dizziness or fainting spells, frequent indigestion, stomach or intestinal trouble, rectal disease, or recent gain or loss of weight. He did indicate that he had arthritis, rheumatism, or bursitis. The absence of complaints or treatment regarding headaches, diarrhea, hair loss, fatigue, and joint pain is probatively significant and given a lot of weight and credibility because this was at a time contemporaneous to the alleged incidents in question. See, e.g., Struck v. Brown, 9 Vet. App. 145, 155-56 (1996). It stands to reason that, if the Veteran did indeed have any problems that begin within six months of him returning from the Persian Gulf, as he is alleged during a March 1996 VA consultation report and at his June 2007 Travel Board hearing, then he would have reported at least a history of having such symptoms during the April 1994 examination from the National Guard (approximately three years after he returned from the Persian Gulf). The Board notes that at his hearing he also indicated that his headaches actually began in service, but he did not report them. Additionally, there is no objective evidence of continuance of symptomatology during the years following the Veteran's return from the Persian Gulf. See Savage, supra (requiring medical evidence of chronicity and continuity of symptomatology). In particular, there is no evidence that the Veteran has chronic complaints of headaches, diarrhea, hair loss, fatigue, and joint and muscle pain. Although there is initial documentation of the Veteran reporting such symptoms between 1996 and 1998, there is nothing beyond these initial complaints until the Veteran reported the symptoms again at his June 2007 Travel Board hearing, approximately ten years later. Between 1996 and 1998, on March 1996 VA consultation report, the Veteran reported that he had complaints of fatigue and muscle pain that started within approximately six months of returning from the Persian Gulf. He indicated that the symptoms started with hair loss, diarrhea, and myalgia involving the upper and lower extremities. He also indicated that he had fatigue in the mornings. On examination, there was muscle tenderness in 10 of the 18 tender spots for fibromyalgia. The assessment was fibromyalgia like symptoms. On May 1997 VA examination, the Veteran reported a history of diarrhea since February 1993. He denied abdominal pain, nausea, vomiting, and bright red blood in stool. He also reported a history chronic arthralgia and fatigue. He had present complaints of arthralgia and hair loss. Other complaints included bleeding gums and hearing loss. A physical examination revealed that his genitourinary system was within normal limits. Laboratory testing revealed that the rheumatoid factor was negative. On May 1997 VA mental status examination, it was noted that the Veteran experienced persistent and recurrent muscle pain with secondary symptoms of anxiety and depression. On May 1997 VA neurological examination, the Veteran reported that he had diarrhea, muscle aches, joint pains, fatigue, hair loss, bleeding gums, and headaches. After examination, he was diagnosed with headaches. A February 1998 VA mental health and treatment plan noted that the Veteran had decreased energy. An August 2000 VA treatment record that included a rheumatology consult noted that the Veteran had fibromyalgia like symptoms, but the Veteran did not show up for the appointment. The Board notes that there are no treatment records past the year 2000 that show present complaints or treatment for headaches, diarrhea, hair loss, fatigue, and joint and muscle pain (beyond any pain described when addressing his service-connected back disability). In February 2008, the Board remanded these claims to obtain treatment records and afford the Veteran an adequate and contemporaneous examination. The Veteran was advised of the consequences in failing to report for the examination without good cause, including possible denial of the claim. See 38 C.F.R. § 3.158 and 3.655. The VA repeatedly tried to contact the Veteran to no avail; therefore, the Board's analysis of the Veteran's claim is limited to the presently available evidence. On review of the record, there was no objective medical evidence of a gastrointestinal disorder manifested by diarrhea. On May 1997 VA examination, a physical examination revealed that his genitourinary system was within normal limits. Although the Veteran indicated during his June 2007 Travel Board hearing that he had an upcoming colonoscopy scheduled with a private physician, when the Board remanded the claim to obtain current records including providing the Veteran with the necessary VA Form 21-2142, the Veteran did not respond. There continues to be no evidence of a gastrointestinal disorder manifested by diarrhea. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1998) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. 38 U.S.C. § 1110 (formerly § 310)). Additionally, there was no probative medical evidence that the Veteran's complaints headaches, diarrhea, hair loss, fatigue, and joint and muscle pain were related to his military service, including his service in Southwest Asia, or to an undiagnosed disability. The Board acknowledges that in March 1996 VA consultation report, the Veteran had complaints of fatigue and muscle pain, hair loss, diarrhea, and myalgia, and it was noted that it was questionable as to whether there was a relation to pulmonary symptoms secondary to Gulf exposure. Likewise, on May 1997 VA neurological examination, the Veteran indicated that while he was in the Persian Gulf, he was located in an area called Khamisiyah, about 15 miles southeast of Annasiriyah in southern Iraq. There were a lot of chemical weapons present in that area when U. S. Forces destroyed a series of ammunition storage bunkers and crated munitions in a pit area. The examiner commented that the blown up chemical ammunitions could have some bearing on the Veteran's symptoms and nature of the headache. This could be secondary to the release of chemical substance. However, the Court has held that medical opinions that are speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). For example, an examiner's opinion that a current disorder "could be" related to, or that there "may be" some relationship with, symptomatology in service makes the opinion of the examiner too speculative in nature. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative). The Board also notes that on a May 1997 VA examination, the examiner found that there was no clearly defined diagnosis explaining the Veteran's symptoms, it was not clear what symptoms the examiner was addressing. During that examination, the Veteran reported a past history of arthralgia and fatigue, and present symptoms of arthralgia and hair loss. Other symptoms reported included bleeding gums and hearing loss. Furthermore, the examiner did not indicate that any such symptoms were due the Veteran's service or to an undiagnosed illness. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000) ("A veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability In summary, there currently is no probative medical nexus evidence of record indicating the Veteran developed headaches, diarrhea, hair loss, fatigue, and joint and muscle pain during or as a result of his service in the military. See Madden v. Gober, 125 F.3d 1477, 1481 (1997) (in evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole). While the Veteran is competent to report that he has continuously experienced headaches, diarrhea, hair loss fatigue, and joint and muscle pain such statements are outweighed by the in service and post service evidence of record. The Board finds that the probative value of such allegation is outweighed by the lack of contemporaneous medical evidence. See Buchanan, supra. Furthermore, there is no probative evidence that the Veteran's headaches, diarrhea, hair loss fatigue, and joint and muscle pain are related to his military service, or to an undiagnosed illness. In this regard, no medical professional has related such disorders to his service or service in Southwest Asia. Therefore, service connection for such disorders is not warranted on either a direct or presumptive basis. Further development or adjudication is not warranted, because, as discussed in detail above, the Veteran has not responded to VA attempts to further develop his claim since his Board hearing in June 2007 and the Veteran's lack of cooperation has resulted in a medical record for complaints of headaches, diarrhea, hair loss, fatigue, joint and muscle pain, and sleep disturbance that essentially stops at in 1998 or at the latest in 2000, over ten years ago. Development of the evidence is incomplete due to the Veteran's lack of cooperation in the development of his claims, and the preponderance of the evidence currently in the claims file is against the Veteran's claims. Accordingly, entitlement to service connection for headaches, diarrhea, hair loss fatigue, and joint and muscle pain, and sleep disturbance, as due to an undiagnosed illness is not warranted. II. Increased Rating Disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Such evaluations involve consideration of the level of impairment of the veteran's ability to engage in ordinary activities, to include employment, as well as an assessment of the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. Where there is a question as to which of two evaluations should 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. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In rating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. Functional impairment shall also be evaluated on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Code 5003. The veteran's statements describing his symptoms are competent evidence to the extent that he can describe what he experiences. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. In cases in which a claim for a higher initial evaluation, as here, stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). At the outset, it is noteworthy that the portion of VA's Ratings Schedule pertaining to evaluation of disabilities of the spine was amended twice during the pendency of this appeal. From their effective dates the veteran is entitled to a rating under the revised criteria (if such are found more favorable). Under the criteria in effect prior to September 23, 2002, intervertebral disc syndrome warrants a 20 percent rating if it is moderate with recurring attacks. A 40 percent evaluation is authorized for intervertebral disc syndrome if it is severe with recurrent attacks and intermittent relief. A 60 percent evaluation is warranted for pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. 38 C.F.R. § 4.71a, Code 5293 (2002). Under the interim revised criteria of Code 5293, effective September 23, 2002, intervertebral disc syndrome is evaluated (preoperatively or postoperatively) either on the total duration of incapacitating episodes over the past 12 months, or by combining under 38 C.F.R. § 4.25 (combined rating tables) separate evaluations of its chronic orthopedic and neurological manifestations along with evaluations for all other disabilities, which ever method results in the higher evaluation. A maximum 60 percent rating is warranted when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent evaluation is assigned for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. A 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months. Note 1 provides that for the purposes of ratings under Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurological manifestations" means orthopedic and neurological signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note 2 provides that when evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurological disabilities separately using evaluation criteria for the most appropriate neurological diagnostic code or codes. 38 C.F.R. § 4.71a, Code 5293 (2003). Under the criteria in effect prior to September 26, 2003, lumbosacral strain was evaluated under 38 C.F.R. § 4.71a, Code 5295 (2003). Lumbosacral strain warrants a 20 percent rating where there is muscle spasm on extreme forward bending, and loss of lateral spine motion, unilateral, in a standing position. A 40 percent rating is warranted for 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 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, Code 5295 (2003). Under the criteria in effect prior to September 26, 2003, limitation of motion of the lumbar spine warrants a 20 percent rating if it is moderate and a 40 percent rating if it is severe. 38 C.F.R. § 4.71a, Code 5292 (2003). Under the criteria in effect prior to September 26, 2003, ankylosis of the lumbar spine warrants a 40 percent evaluation if it is favorable or a 50 percent evaluation if unfavorable. 38 C.F.R. § 4.71a, Code 5289 (2003). Complete bony fixation (ankylosis) of the spine at an unfavorable angle with marked deformity and ankylosis of major joints or without other joint involvement warrants a 100 percent rating. 38 C.F.R. § 4.71a, Code 5286 (2003). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more of less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Under the criteria effective from September 26, 2003, lumbosacral strain, spondylolisthesis, and degenerative arthritis of the spine are rated under the general rating formula for rating diseases and injuries of the spine (outlined below). 38 C.F.R. § 4.71a, Codes 5237 and 5242 (2007). Intervertebral disc syndrome is rated under the general formula for rating diseases and injuries of the spine or based on incapacitating episodes (outlined above), whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Code 5243 (2007). Under the general rating formula for rating diseases and injuries of the spine, effective September 26, 2003, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes set out after the diagnostic criteria, which provide the following: First, associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. 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 to 140 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. Throughout the appeal period, the Board finds that, based on the facts shown, the Veteran's low back disability was manifested by no more than a moderate loss of range of motion of the lumbar spine. See Fenderson, supra. The Board notes that on November 1998 VA examination, it was noted that the Veteran could forward flex from 0 to 20 degrees and had full painless range of motion in all other planes of movement. However, this appeared to be an anomaly as the majority of the Veteran's treatment records and evaluations reported his forward flexion from anywhere from 45 to 90 degress. Furthermore, at the time of the November 1998 VA examination, the examiner specifically noted that forward flexion was noted to be normal when the Veteran was removing his shoes. Given what appears to be inconsistencies in the Veteran's forward motion, this examination report lacks probative value. On the prior June 1997 VA examination, the Veteran could flex to 90 degrees, extend to 30 degrees, right and left bend to 17 degrees, and rotate on each side to 45 degrees. There was pain on the extremes of motion. Subsequent treatment records included an April 2001 record that revealed that forward flexion was 25% (or to 72 degrees) limited and reproduced pain. Extension was 75% limited (or to 8 degrees) and reproduced pain. Right side bending was 50% limited (or to 15 degrees) and left side bending was 25% limited (or to 23 degrees). He was without evidence of acute neuro- deficit and symptoms of radicular pain. A May 2001 treatment record reported that forward flexion was 50% (or to 45 degrees) and extension was 50% (or to 15 degrees), with pain in all planes. On December 2006 VA examination, the Veteran had right and left lateral bending and extension from 0 to 30 degrees, flexion from 0 to 60 degrees, and right and left rotation from 0 to 70 degrees with cog wheeling and jerking and multiple expressions of pain, but no evidence of an increased pulse rate. The examiner indicated that were no DeLuca factors present on any of the above. Here, the evidence indicated that the Veteran's range of motion of the lumbar spine more closely approximated a moderate loss, which warranted a 20 percent rating, but no higher, throughout the appeal period. Even considering the DeLuca factors, there was no probative evidence of severe limitation of motion to warrant a 40 percent rating under Code 5292. Also, x-rays demonstrated that there was no vertebral fracture to warrant an extra 10 percent rating for demonstrable deformity of a vertebral body from fracture. In order to warrant a rating in excess of 20 percent, the Board considered other potentially applicable codes. Although a review of the record showed that there was tenderness to palpation over the lumbosacral area, on June 1997 and December 2006 VA examinations, and spasm was noted on an August 2001 VA treatment record, there was no evidence of severe lumbosacral strain with listing of the whole spine, positive Goldthwaite's sign, marked limitation with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion, which was necessary findings to achieve a 40 percent rating under Code 5295. No such symptoms were clinically shown. There was also no evidence to support a rating in excess of 20 percent under the criteria governing intervertebral disc syndrome under the criteria in effect prior to September 23, 2002, that required severe intervertebral disc syndrome with recurring attacks and only intermittent relief (Code 5293). See 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2000). Throughout the appeal period the Veteran had complaints of chronic low back pain without radiation. At his June 2007 Travel Board hearing, he indicated that he experienced pain on a regular basis. An August 2001 record revealed that he had degenerative disc disease of the lumbar spine and an MRI showed significant herniated disc disease. However, the Board finds that the symptoms presented did not rise to the level of recurring attacks of severe intervertebral disc syndrome with only intermittent relief to warrant a 40 percent rating under Code 5293. On November 1998 VA examination, it was noted that the Veteran had complaints of chronic low back pain without radiation. He denied any numbness, tingling, or weakness of the extremities. On examination, there was no swelling, increased heat, or erythema in any joint. There was no atrophy or fasciculation of the paraspinal muscles. The musculature of the upper and lower extremities was symmetrical. Tenderness to palpation was noted over the SI joints bilaterally. There was no tenderness to palpation of the spinous process or paraspinal muscles. Spinal curvature was noted to be intact. He could stand on his heels and toes. The gait was fluid without impediment. X-rays of the lumbar spine were negative. An April 2001 VA treatment record reported that the Veteran was without evidence of acute neuro- deficit and symptoms of radicular pain. In May 2001, straight leg raising was negative for radicular symptoms. On December 2006 VA examination, it was noted that the Veteran never had back surgery. He indicated that he had pain all day every day. There was no radiation, numbness, weakness, or bowel or bladder incontinence. He had erectile dysfunction. He wore a brace. There was no physician-directed bedrest. He was unable to bend, crawl, or sit for more than 10 minutes. He had no difficulty walking. On examination, he walked without a limp using no assistive device. There was tenderness to extremely light palpation on the right lower lumbar region. He had positive axial compression pain. There was positive truncal rotation pain and a positive Burn's test. He had positive straight leg raising bilaterally while sitting, in which he was able to extend his knees to 0 with him reporting pain in the right low back with both legs. In the supine position, he had exquisite positive straight leg raising with pain at 30 degrees on the left and 20 degrees on the right. The examiner noted that at the end of the examination, the Veteran sat straight up from the supine position without the use of his arms. The impression was that he had a lumbar strain with facet arthritis with significant symptoms magnification on examination. Therefore, there was also no evidence that the veteran suffered from mild, incomplete paralysis of the sciatic or peroneal nerve so as to warrant a separate compensable rating based on neurological residuals. See 38 C.F.R. § 4.124a, Codes 8520, 8521. Effective from September 23, 2002, VA's rating schedule allowed for intervertebral disc syndrome to be rated either on the basis of the total duration of incapacitating episodes over the past 12 months, or by combining separate evaluations for orthopedic and neurologic manifestations, whichever method results in a higher evaluation. Here, the medical evidence does not show, nor does the Veteran allege, that he has had any incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months that would warrant a higher 40 percent rating. On December 2006 VA examination, it was specifically noted that there was no physician-directed bedrest. The orthopedic manifestations of the Veteran's service connected disability are no more than moderate at worst, warranting no more than a 20 percent rating. This 20 percent rating may be combined with a rating for the neurological manifestations of the disability. As mentioned above, multiple VA examinations indicated that there was no evidence of radiculopathy related to the veteran's low back strain. Therefore, a compensable (10 percent) rating under Code 8520 (which would be combined with the rating for orthopedic manifestations) is not warranted. Under the most recent revision (effective September 26, 2003), intervertebral disc syndrome (Code 5243) may be rated either under the General Rating Formula for Diseases and Injuries of the Spine or based on incapacitating episodes, whichever method results in the higher rating. As incapacitating episodes of a total duration of at least four weeks but less than six weeks during the past 12 months were not shown, a higher rating on that basis is not indicated. Under the General Rating Formula (which also includes lumbosacral strain), a rating in excess of 20 percent is only possible when there is ankylosis or limitation of thoracolumbar spine with forward flexion to 60 degrees or less. After reviewing the entire disability picture, and multiple records and VA examinations reports, the Veteran's forward flexion mostly ranged between 45 and 90 degrees. Therefore, a 20 percent rating, but no higher under the General Rating Formula is warranted. Additional factors that could provide a basis for an increase have also been considered. However, it is not shown that the Veteran has any functional loss beyond what he is presently being compensated for in the 20 percent rating. 38 C.F.R. §§ 4.40, 4.45, Deluca v. Brown 8 Vet. App. 202 (1995). The Board notes that the RO had assigned staged ratings to this disability. Specifically, the RO has assigned this disability a 10 percent rating prior to December 21, 2006 and a 20 percent rating from that date. After reviewing the evidence of record, the Board concludes that the Veteran's service-connected low back strain warrants a 20 percent disability rating. Thus, with application of the benefit-of- the-doubt rule, 38 U.S.C.A. § 5107(b), the Board finds that during the course of the appeal period prior to December 21, 2006, a higher rating of 20 percent is warranted for the Veteran's low back strain. However, there is a preponderance of the evidence against a rating in excess of 20 percent at any point throughout the appeal. 38 U.S.C.A. § 5107. There are no identifiable periods of time, throughout the appeal period in which the Veteran's low back strain had been persistently more severe than the extent of disability contemplated under the assigned 20 percent rating, and thus higher "staged ratings" are not warranted. Fenderson, supra. The record does not show, nor does the Veteran contend, that unemployment arises from the service connected low back strain. Thus, the issue of entitlement to total disability based upon individual unemployability (TDIU) is not for present consideration. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Finally, the Board has considered whether there is evidence showing that the Veteran's service-connected disability should be referred for assignment of an extraschedular rating. The record does not show that this disability has markedly interfered with his employment status beyond that interference contemplated by the assigned rating, and there is also no indication that this disability has necessitated frequent, or indeed any, periods of hospitalization during the pendency of this appeal. In the absence of an unusual disability picture such as one involving marked interference with employment or frequent hospitalization, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Thun v. Peake, 22 Vet. App. 111 (2008). III. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim, as well as what parts of that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b) (2009). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). Furthermore, the VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must specifically provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). VA complied with notification responsibilities in regards to the Veteran's claims for service connection in correspondence sent to the Veteran in May 2006 and May 2008. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. These letters also provided notice pursuant to the Dingess decision. The claims were subsequently readjudicated in April and May 2010 supplemental statements of the case (SSOC's). In regards to the claim seeking an initial compensable rating for a low back strain, as the December 1997 rating decision that is on appeal granted service connection for a low back strain and assigned a rating and an effective date for the award, statutory notice had served its purpose and its application was no longer required. See Dingess/Hartman, supra. Also, a January 2007 rating decision increased the rating to 20 percent disabling effective from December 21, 2006. Notably, the May 2008 letter also provided the Veteran with notice on the "downstream" issues of disability rating and effective date criteria. April and May 2010 SSOC's readjudicated the matter after the Veteran had ample opportunity to respond and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). Neither the Veteran nor his representative have alleged that notice as to this matter was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) VA has also made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A (West 2002). The information and evidence currently associated with the claims file consists of the Veteran's service treatment and personnel records, post- service VA and private medical records, VA examination reports, and the transcript from a June 2007 Travel Board hearing. As previously mentioned, the Veteran's STR's are incomplete. The record shows that the Veteran's STR's have been requested and in May 1997, the Adjutant General's Office for the State of New Jersey indicated that there were no records for the Veteran. The Board finds that an attempt to obtain any missing records would be futile. September 1997 correspondence from the Veteran shows that he was aware that his service records were missing. In cases where the Veteran's STR's are unavailable through no fault of the claimant, there is a heightened obligation to assist the claimant in the development of his case. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The Board notes that the May 2008 notice letter advised the Veteran to submit alternative evidence such as lay testimony, records and statements form service medical personnel, employment physical examinations, medical evidence of treatment since military service, pharmacy records, and/or insurance examination reports in support of his claim. The Board notes that the Veteran has not indicated that he received any treatment in service for symptoms related to an undiagnosed illness. During his June 2007 Travel Board hearing, he specifically indicated that he did not receive treatment in service for his headaches, and that the other claimed symptoms did not begin until after his return from the Persian Gulf. The Veteran did not respond to the May 2008 notice letter. As previously mentioned, although the Veteran indicated during his June 2007 Travel Board hearing that he had an upcoming colonoscopy scheduled with a private physician, when the Board remanded the claim to obtain current records including providing the Veteran with the necessary VA Form 21-2142, the Veteran did not respond. Here, the RO/AMC has either obtained, or made sufficient efforts to obtain, records corresponding to all treatment for the claimed disorder described by the Veteran. Additionally, the RO attempted to provide the Veteran with a VA examination regarding his undiagnosed illnesses in compliance with the Board's February 2008 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In March 2010, the Veteran's examinations were cancelled as the Veteran indicated that he needed more time to prepare of this appointment. In April 2010, VA contacted the Veteran numerous times in an attempt to clarify his request. His phone numbers on file were disconnected. In a July 2010, appellant's post-remand brief, the Veteran's representative noted that numerous attempts to contact the Veteran failed. The law provides that while VA is obligated to assist a claimant in the development of a claim, there is no duty on VA to prove the claim. As the Court stated in Wood v. Derwinski, "[t]he duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." 1 Vet. App. 190, 193, reconsidered, 1 Vet. App. 406 (1991); see also Wamhoff v. Brown, 8 Vet. App. 517 (1996). Moreover, the Veteran, alone, is responsible to keep the RO informed of his current address and phone number, and to report any changes in a timely manner. If he does not do so, "there is no burden on the part of the VA to turn up heaven and earth to find him." See Hyson v. Brown, 5 Vet. App. 262, 265 (1993). Under the circumstances of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the record is ready for appellate review. ORDER Service connection for a variously diagnosed psychiatric disorder, including PTSD is granted. Service connection for headaches, diarrhea, hair loss, fatigue, a sleep disorder, and for joint and muscle pain, all due to an undiagnosed illness is denied. Prior to December 21, 2006 a 20 percent rating, but not more, for a low back strain is granted, subject to the controlling laws and regulations governing the payment of monetary awards, and from December 21, 2006 a rating in excess 20 percent rating for a lumbar spine disorder is denied. ____________________________________________ MARY GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs