Citation Nr: 1035273 Decision Date: 09/20/10 Archive Date: 09/28/10 DOCKET NO. 06-03 885 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California THE ISSUES 1. Entitlement to service connection for residuals of trauma to the neck due to repetitive motion. 2. Entitlement to service connection for carpal tunnel syndrome of the right wrist. 3. Entitlement to service connection for a left wrist disorder, including carpal tunnel syndrome. 4. Entitlement to service connection for sleep apnea. 5. Entitlement to an increased rating in excess of 20 percent for low back pain with schmorl's nodes at L2, L3 and L5, with degenerative disc disease. 6. Entitlement to an effective date earlier than August 25, 1999 for the grant of service connection for depressive disorder. 7. Entitlement to a combined evaluation greater than 60 percent from August 25, 1999. 8. Entitlement to an effective date earlier than October 14, 2005 for the assignment of a combined evaluation of 70 percent. 9. Entitlement to a total disability evaluation by reason of individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from September 1988 to January 1992. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. By a rating action in May 2004, the RO granted service connection for depressive disorder, evaluated as 50 percent, effective August 25, 1999. The Veteran perfected an appeal of the effective date assigned and the combined disability evaluation. In April 2006, the RO denied a claim for a rating in excess of 20 percent for low back pain with schmorl's nodes L2/3 and 5 with degenerative disc disease, and a claim for individual unemployability. Subsequently, in a rating action dated in January 2007, the RO denied the claims for service connection for carpal tunnel syndrome, service connection for sleep apnea, and service connection for trauma to the neck due to repetitive motion. On January 28, 2010, the Veteran appeared and offered testimony at a hearing before the undersigned Veterans Law Judge, sitting at the RO. A transcript of that hearing is of record. At the hearing, the Veteran submitted additional evidence for which he has provided written waiver of RO review under 38 C.F.R. § 20.1304 (2009). (The issues of entitlement to service connection for sleep apnea, service connection for carpal tunnel syndrome of the right wrist, an increased rating for the lumbar spine, entitlement to earlier effective dates for combined ratings of 60 percent and 70 percent, and entitlement to a TDIU are addressed in the REMAND portion of the decision below.) FINDINGS OF FACT 1. The Veteran did not experience trauma to the neck during military service. 2. A cervical spine disorder was not manifest during service, arthritis was not manifest within a year after discharge, and a current cervical spine disorder is not traceable to military service. 3. A current left wrist disorder is not related to military service. 4. The Veteran did not file his claim of service connection for a psychiatric disorder within one year of discharge from service. 5. On July 23, 2003, the RO received the Veteran's claim of entitlement to service connection for a psychiatric disorder, claimed as secondary to his service-connected lumbar spine and bilateral knee disabilities. Submitted in support of the claim was a VA clinical report dated August 25, 1999, which reflects a diagnosis of depression secondary to his service-connected disorders; no formal or informal claim for depression was received prior to August 25, 1999. CONCLUSIONS OF LAW 1. The Veteran does not have a neck disability that is the result of disease or injury incurred in or aggravated by active military service, nor may cervical spine arthritis be presumed to have been incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2009). 2. The Veteran does not have a left wrist disorder that is the result of disease or injury incurred in or aggravated by active military service, nor may left wrist arthritis be presumed to have been incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2009). 3. The criteria for an effective date earlier than August 25, 1999, for the award of service connection for a depressive disorder have not been met. 38 U.S.C.A. §§ 5103, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.159, 3.400 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of letters dated in September 2003, September 2005, November 2005 and August 2006 from the RO to the Veteran, which were issued prior to the RO decisions in May 2004, April 2006, and January 2007. An additional letter was issued in May 2008. Those letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to his claims has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of the issues decided herein. The Board is unaware of any outstanding evidence or information that has not already been requested. Therefore, the Board is satisfied that the RO has complied with the duty-to-assist requirements of the VCAA and the implementing regulations. Neither the Veteran nor his representative has contended that any evidence relative to the issues decided herein is absent from the record. A review of the Veteran's service records contains no evidence of trauma to the neck or a left wrist disorder. In addition, the Veteran has provided no competent information regarding the etiology of those disorders. Therefore, it is not necessary for VA to schedule the Veteran for an examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. Therefore, no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual Background The Veteran entered active duty in September 1988. The service treatment records (STRs) do not reflect any trauma to the neck; they likewise do not reflect any complaints or treatment for problems involving the left wrist. A medical board report in October 1991 did not reveal any disability involving the neck or the left wrist. An initial VA examination conducted in March 1992 was also silent with respect to any complaints or clinical findings of a neck disorder or a left wrist disorder. Medical evidence of record, including VA as well as private treatment records from January 1993 through January 2004, show that the Veteran received clinical evaluation and treatment for neck pain and a left wrist disorder. Among these records is a neurological evaluation conducted by Dr. James Santiago Grisolia in May 1993. It was noted that the Veteran had been seen for evaluation and treatment of injuries following an industrial incident occurring on April 8, 1993. The Veteran reported being assaulted by a fellow employee. Dr. Grisolia indicated that, on initial presentation to the office, the Veteran had residual nonradiating neck and low back pain. A VA medical certificate indicates that the Veteran was seen on September 21, 1999, with complaints of low back and neck pain associated with a motor vehicle accident that occurred that day. The diagnostic impression was cervical sprain. A VA progress note dated in March 2000 reflects an impression of clinical depression. An April 2001 VA progress note reflects an assessment of partially treated depression. In a statement in support of claim (VA Form 21-4138), dated in July 2003, the Veteran indicating that he was seeking to establish service connection for post-traumatic stress disorder due to his service-connected disabilities. Submitted in support of the claim were VA progress notes dated from July 1995 to January 2004. On August 25, 1999, the Veteran was seen at the psychiatric clinic; it was noted that the Veteran was referred for evaluation of depression. The Veteran reported that he had had a back injury in 1993, which was followed by increased depressed mood, insomnia, early morning wakening, poor concentration, reduced appetite, low energy, anhedonia, and reduced libido. The Veteran reported recent worsening of depressed mood. The pertinent diagnoses were depression, not otherwise specified (NOS) and pain disorder. A September 2003 VA progress note reflects an assessment of major depressive disorder. The Veteran was afforded a VA examination in February 2004. At that time, the examiner noted that clinical notes from 2003 to 2004 showed that the Veteran had problems with anxiety, insomnia, appetite and weight loss, with a diagnosis of major depressive disorder. He also noted that the file clearly documents chronic problems with back and leg pain, with some physicians having diagnosed fibromyalgia. Following a mental status examination, the examiner reported a diagnosis of depressive disorder, NOS. The examiner stated that this depressive disorder appears as likely as not to be secondary to the Veteran's painful service- connected health problems including traumatic arthritis and knee conditions. By a rating action in May 2004, the RO granted service connection for depressive disorder; a 50 percent disability rating was assigned, effective August 25, 1999. Of record are private treatment reports from Kaiser Permanente, dated from January 2005 to April 2005. These records indicate that the Veteran was seen at a clinic on January 3, 2005 for complaints of pain in the left hand. The Veteran indicated that he suffered a left wrist injury when he hit his left hand/wrist into the dashboard of his car during a motor vehicle accident the previous day. X-ray study of the left hand/wrist revealed fractures of the left 3rd and 4th metacarpal joints. A cast was applied to the left hand. Treatment records from Dr. Stanley Besser dated from March 2005 to April 2005 reflect diagnoses of right hand/wrist tenosynovitis and neck sprain. In April 2005, the Veteran was seen for complaints of increased pain in his right hand; he also reported numbness. The diagnoses were right wrist sprain, right hand sprain, right hand paresthesias, cannot rule out carpal tunnel syndrome, and neck sprain. Of record is the report of an orthopedic consultation conducted by Dr. Jeffrey P. Bernicker in June 2005. Dr. Bernicker indicated that the Veteran was seen in his office in June 2005 for consultation regarding symptoms in his neck and right upper extremity relating to an industrial injury sustained on February 17, 2005. It was noted that the Veteran began working as a claims examiner on May 1, 2001. The physical requirements of his job included sitting, twisting, reaching, pushing, pulling, lifting, keyboarding, and grasping. The Veteran indicated that he began experiencing symptoms in his neck in May 2004; he stated that he noticed the symptoms in his neck and right upper extremity which he believed to be associated with repetitive use while performing data entry at a computer. The Veteran stated that his workstation was not ergonomically sound. He denied any acute episode of trauma. Due to a persistence of his symptoms, on February 17, 2005, he formally reported the injury as being work related. Following a physical evaluation, the impression was industrial overuse disorder secondary to cumulative trauma exposure; chronic cervical strain with right upper extremity radiculopathy and suspected right carpal tunnel syndrome. The examiner stated that, from the history and records provided, it appeared reasonable to assume that the Veteran became symptomatic with respect to his neck and right upper extremity as a result of repetitive activities occurring during the course of and arising out of his employment. Treatment records from Dr. Jeffrey P. Bernicker dated from July 2005 to August 2005 show that the Veteran was treated for pain in the right wrist and cervical spine. The pertinent diagnosis was sprains/strains in the neck. During a neurological consultation in November 2005, the Veteran reported being injured in a motor vehicle accident in September 2005. It was noted that the Veteran was seated in a vehicle that was rear-ended. The Veteran indicated that he subsequently went to the emergency room at Kaiser Permanente where he was told that he had neck and lumbar strain. Following a clinical evaluation, the Veteran was diagnosed with cervical and lumbar strain. Of record is the report of a medical evaluation conducted by the State Compensation and Insurance agency in February 2006. It was noted that his complaints involved pain in the neck, shoulders and lower back. He was diagnosed with a cervical spine disorder, carpal tunnel syndrome in the right wrist, DeQuervain's tenosynovitis, right wrist, and DeQuervain's tenosynovitis of the left wrist. The examiner determined that the disabilities involving the right wrist, neck and bilateral upper extremities were due to the Veteran's employment at the Employment Development Department. On the occasion of a VA examination in March 2006, it was noted that the Veteran's primary complaint was pain in his neck and arms. The Veteran stated that he has been diagnosed with carpal tunnel syndrome in his right hand and fractured his left hand a couple of years earlier in a car accident, and possibly has been diagnosed with spinal stenosis of his cervical spine. He dated the onset of the pain in his neck to be approximately 2004. The pertinent diagnoses were chronic cervical degenerative disk disease C5/C6 with retrolisthesis; and old fracture, left hand. (A VA examination report dated in March 2006 reflects a diagnosis of carpal tunnel syndrome, right hand.) The report of a Cal Pers Report, dated in September 2006, noted that the Veteran was involved in a motor vehicle accident on January 2, 2005, which resulted in a fracture of the left hand that resolved except for some minimal tenderness in the palm. It was noted that other illnesses included cervical spondylosis at C4-5 and L2 through L5 in the lumbar spine. It was further noted that he has been diagnosed with bilateral carpal tunnel syndrome and sleep apnea. Following an evaluation, the pertinent diagnoses were possible mild cervical spondylosis; repetitive motion injury, upper extremities, bilaterally, with mild adhesive capsulitis of the shoulders; tendonitis affecting the forearms, mild median neuropathy, right wrist; and work aggravation of a pre-existing degenerative disc disease of the lumbar spine. The examiner determined that the Veteran's disabilities began in May 2004. Received in April 2007 were treatment reports from Dr. Jeffrey P. Bernicker, dated in March and April 2007. These records show that the Veteran received follow-up evaluation and treatment for pain in the right hand and wrist. At his personal hearing in January 2010, the Veteran testified that his cervical spine disorder is related to his low back disorder; he explained that low back pain radiates up the neck and down into the hands. The Veteran indicated that his left hand disorder is also related to the low back disorder. The Veteran reported that he has been dealing with depression since he was discharged from service; as a result, he asserts that service connection for depression should be made effective from January 1992. III. Legal Analysis-Service Connection Service connection may be granted for a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1131. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"--the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Holton v. Shinseki, 557 F.3d 1362 (2009). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2009). For certain chronic diseases, such as arthritis, a presumption of incurrence or aggravation during service arises if the disease is manifested to a degree of 10 percent within a year following discharge from service. 38 C.F.R. § 3.307, 3.309. While the disease need not be diagnosed within the one-year period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Veteran can attest to factual matters of which he has first- hand knowledge, such as experiencing certain symptoms, such as pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition, (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In such cases, the Board must weigh the evidence and make credibility and competency determinations. See Barr v. Nicholson, 21. Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2010). A. Left Wrist At the outset, the Board has considered whether a presumption under 38 C.F.R. § 3.307 for chronic disease is warranted in the instant case. (Under 38 C.F.R. § 3.309(a), arthritis is regarded as a chronic disease.) However, in order for the presumption to operate, such disease must become manifest to a degree of 10 percent or more within one year after separation from qualifying service. See 38 C.F.R. § 3.307(a) (3). As the evidence of record fails to establish any clinical manifestations of arthritis of the left wrist within the applicable time period, the criteria for award of service connection on the basis of the § 3.307 presumption are not met. The service treatment records do not indicate complaints or treatment referable to a left wrist disability, or for tendinitis. Moreover, in-service physical examinations showed normal findings. Following separation from active service, treatment reports indicate that the Veteran suffered a fractured left wrist due to a car accident on January 2, 2005. The March 2006 VA examination report noted a left hand fracture from the January 2005 motor vehicle accident and neck pain beginning in 2004. In light of the foregoing, the Board notes that the first post- service evidence of a left wrist disorder is not shown until January 2005, several years following the veteran's separation from active service. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, supra. As the veteran is claiming that his current left wrist disability relates back to active service, his statements imply that he has experienced continuous left wrist symptomatology since that time. In this regard, the Veteran is competent to give evidence about what he experienced; for example, he is competent to discuss his current pain and other experienced symptoms. See, e.g., Layno v. Brown, supra. Furthermore, lay evidence concerning continuity of symptoms after service, if credible, may help prove the Veteran's claim. Buchanan v. Nicholson, supra. However, in the present case, the absence of documented complaints or treatment for a left wrist disorder several years following military discharge is found to be more probative than any recollection as to symptoms experienced in the past. The Veteran has implied that he had had trouble since service, but his statements are not supported by the record. Even records prepared after the 2005 accident show that the Veteran gave a history consistent with a conclusion that his wrist problem originated with the post-service injury. Therefore, continuity has not here been established, either through the competent evidence or through his statements. Moreover, no competent evidence causally relates a current left wrist disorder to military service. Rather, the evidence of record establishes that the Veteran's sustained a left wrist injury as a result of a motor vehicle accident in January 2005 and has had problems since that time. In addition, a Cal Pers Report in September 2006 concluded that the Veteran's disabilities were work related and began in 2004. In sum, the evidence of record does not support a grant of service connection for a left wrist disorder. As the preponderance of the evidence is against the claim, the benefit- of-the-doubt rule is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. B. Neck The pertinent evidence of record, as detailed above, does not support the Veteran's claim of entitlement to service connection for trauma to the neck. In this regard, the STRs do not reflect any complaints or treatment for a neck injury or a cervical spine disorder. First, there is no evidence that any arthritis of the cervical spine was manifested during the applicable one-year presumptive period after separation from active military service. Further, there is no radiographic evidence of arthritis during service or within the year following his discharge. The Veteran's post-service records are also silent as to a cervical spine disorder until he was involved in an industrial accident in April 1993. Subsequently, he was diagnosed with cervical sprain in September 1999 associated with a motor vehicle accident. Indeed, during an orthopedic consultation in June 2005, the Veteran reported that he began experiencing symptoms in his neck in May 2004. Following a medical evaluation conducted in February 2006, the examiner concluded that the Veteran's neck disability was due to his employment. As the most probative evidence of record clearly indicates that the Veteran did not incur any neck injury or disease in service or as a result of a service-connected disorder, and the Veteran does not allege that he did, the claim of entitlement to service connection for a neck disorder is denied. The preponderance of the evidence is against the claim. IV. Earlier effective date--Depression In general, the date of entitlement to an award of service connection will be the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise, it will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i) (2009). Where the claim is received more than one year following service separation, as here, the effective date of an award is the date of receipt of the claim, or the date entitlement arose, whichever is later. Unless specifically provided otherwise in the statute, the effective date of an award based on an original claim or a claim reopened after final adjudication shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the claim. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400 (2009). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1(p); see also Brannon v. West, 12 Vet. App. 32, 34-5 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). Any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA, from a Veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the Veteran, it will be considered filed as of the date of receipt of the informal claim. Once a formal claim for pension or compensation has been allowed or a formal claim for compensation has been disallowed for the reason that the service-connected disability is not compensable in degree, receipt of a report of examination or hospitalization by VA or the uniformed services will be accepted as an informal claim for benefits. The date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. 38 C.F.R. § 3.157. After a review of the claims folder, the Board notes that the Veteran's claim for service connection for PTSD secondary to his service-connected back disorder was received at the RO in July 2003. This is considered an original claim, which was received more than one year after the Veteran's date of separation from service. The RO had determined that the earliest document which could be construed as a claim for service connection for a psychiatric disorder was a VA treatment report dated August 25, 1999. Why the RO determined that this report represented a claim of service connection is not clear except that it suggested a relationship with service-connected disability. There is no communication of record from the Veteran or any representative or other party to VA that would constitute a claim for service connection for depression prior to the August 25, 1999, report. 38 C.F.R. § 3.155. Accordingly, the applicable regulation for a claim for service connection received more than one year after the date of separation from service dictates that the effective date is the date of receipt of the claim, or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. In sum, when the Veteran's treatment records and statements are considered, it is clear that no claim or information indicating a desire to seek service connection for depression was made prior to August 25, 1999. Therefore, the Board concludes that the Veteran's claim for service connection for depression was not received by the RO prior to August 25, 1999. Therefore, the effective date can be no earlier than the date already established by the RO. As the preponderance of the evidence is against the claim, the Board finds that an effective date earlier than August 25, 1999, for service connection for depression is not warranted. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Service connection for residuals of trauma to the neck is denied. Service connection for a left wrist disorder is denied. Entitlement to an effective date prior to August 25, 1999, for the grant of service connection for depression is denied. REMAND As noted above, the VCAA requires that VA must provide notice that informs the claimant (1) of the information and evidence not of record that is necessary to substantiate the claim, (2) of the information and evidence that VA will seek to provide, and (3) of the information and evidence that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). After examining the record, the Board concludes that further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C.A. § 5103A. A. Sleep Apnea The Veteran contends that he has suffered from symptoms of sleep apnea, including insomnia and fatigue, since his discharge from military service. The Veteran's service treatment records demonstrate that in July 1989, he complained of insomnia and malaise for the previous three weeks; it was noted that he was prescribed medication. Post-service VA treatment records reflect a diagnosis of, and treatment for sleep apnea as early as April 2001. During a clinic visit in April 2001, the Veteran reported problems with ongoing fatigue, lack of restful sleep, and loud snoring. Sleep apnea was to be ruled out. The Veteran underwent a pulmonary sleep study consultation in May 2006. The impression was severe obstructive sleep apnea syndrome with severe desaturations in a patient with symptoms suggestive of sleep disordered breathing. It was noted that he had significant snoring and witnessed apneas. After reviewing the foregoing evidence, the Board finds that a VA medical examination and opinion would be useful in assessing the claim. VA has a duty to afford a Veteran a medical examination or obtain a medical opinion when necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (d). When the medical evidence is not adequate, VA must supplement the record by seeking an advisory opinion or ordering another examination. See McLendon v Principi, 20 Vet. App. 79 (2006). In the present case, there is medical evidence showing a current disability, objective evidence of symptoms in service, and a lay evidence indicating continuity since service. In light of these factors, the Board finds that a VA examination is necessary to determine whether it is at least as likely as not that the veteran's current sleep apnea is related to the insomnia for which he was treated during his period of service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). B. Right Wrist The Veteran maintains that his currently diagnosed carpal tunnel syndrome of the right wrist is related to a service injury. The service treatment reports show that he was seen in November 1989 for evaluation of complaints of pain in the right wrist. The Veteran reported noticing pain while lifting weights 3 days earlier. Following an evaluation, the Veteran was diagnosed with ulnar tendon strain. Post-service treatment records show that the Veteran has received ongoing treatment for a right wrist disorder. The records indicate that the Veteran sustained a work-related injury to the right wrist in February 2005. He was diagnosed with carpal tunnel syndrome. During a clinic visit in April 2005, the Veteran indicated that he was waiting for the fracture in his left hand to heal from the car accident. It was noted that he had not worked since a car accident on January 2, 2005. It was reported that the Veteran was in good spirits despite his physical condition of back pain, carpal tunnel syndrome of the right wrist and fracture of the left wrist from a car accident on January 2, 2005. A clinic progress note dated in February 2005 indicates that the Veteran was seen for complaints of right hand pain. He reported right hand/wrist pain. The assessment was carpal tunnel syndrome. A splint was applied to the wrist. VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A (d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As noted above, the Veteran was treated for a tendon strain in the wrist area during service. Furthermore, the Veteran is competent to attest that he has had continuing pain and numbness in the right wrist since service. Consequently, his reports of continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. See, McLendon, supra. Therefore, the Board finds that the Veteran should be afforded a VA examination to determine whether he has current right wrist disorder(s), and, if so, whether any such disorder is related to service. C. Rating for Low Back Disability The Veteran maintains that his low back disorder has increased in severity. He indicates that he has increased pain with activity, especially prolonged sitting and repetitive movement. The Veteran also reports problem with radiating pain into his lower extremities. The Veteran further maintains that he has been told that he will require surgery in the near future. During his January 2008 Board hearing, the Veteran testified that his lumbosacral strain had worsened since his most recent VA Compensation and Pension examination in March 2006. The Veteran reported increased pain and difficulty doing chores. Where the Veteran asserts that a disability has worsened since his last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); and also VAOPGCPREC 11-95 (1995). Thus, a new VA examination is required to determine the nature and severity of the Veteran's low back pain with schmorl's nodes and degenerative disc disease. (The issue of entitlement to TDIU is inextricably intertwined with the claim of an increased disability rating for service- connected low back disability. In other words, if an increased disability rating is granted for the low back disability, this may impact the TDIU claim. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001) [noting that where the facts underlying separate claims are "intimately connected," the interests of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together]; see also Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [two or more issues are inextricably intertwined if one claim could have significant impact on the other]. Action on the Veteran's TDIU claim is therefore deferred. Action is also deferred on the questions of the effective dates for the combined ratings. Should service connection be granted for sleep apnea or right wrist disability, or an increased rating granted for the service- connected low back disability, the calculation of combined ratings and the effective dates for those ratings may be affected. Consequently, the Board will not act on these issues until after the development sought in this remand is completed.) In light of the discussion above, and to ensure full compliance with due process requirements, the Board finds that further development is necessary prior to appellate review. Accordingly, the case is REMANDED to the agency of original jurisdiction (AOJ) for the following actions: 1. The AOJ should contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all health care providers, VA and private, who may possess additional records pertinent to his claims remaining on appeal. The AOJ should attempt to obtain and associate with the claims file any medical records identified by the Veteran that have not been secured previously. If the AOJ is unsuccessful in obtaining any medical records identified by the Veteran, it should inform him and his representative of this and ask them to provide a copy of additional medical records they may have obtained on their own that have not been secured previously. 2. The Veteran should be afforded a VA examination in order to determine the etiology of his current sleep apnea condition. The claims file must be made available to the designated examiner, and the report of the examination should include discussion of the Veteran's documented medical history and assertions. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that any current sleep apnea had its onset in service or is otherwise the result of a disease or injury incurred during active military service. The rationale for any opinions should also be provided. 3. Thereafter, schedule the veteran for a VA examination of his right wrist to determine the nature and etiology of each right wrist disorder. The claims file must be made available to the designated examiner, and the report of the examination should include discussion of the veteran's documented medical history and assertions. The examiner should clearly identify each current right wrist disability, to specifically include whether the veteran currently has carpal tunnel syndrome. With respect to each such diagnosed disability, the examiner should offer an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that such disability is medically related to the veteran's active military service. The examiner should set forth all examination findings, along with a complete rationale for all opinions rendered, in the examination report. 4. The Veteran should also be afforded an examination in order to determine the severity of the service-connected low back disability. The claims file must be made available to and reviewed by the examiner prior to the requested examination. The examiner should identify any orthopedic and neurological findings related to the service-connected disability and fully describe the extent and severity of those symptoms. The examiner should also document the number of weeks, if any, during any 12- month period, that the Veteran has had "incapacitating episodes," defined as 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. Range-of-motion studies should be conducted and all functional losses, such as due to pain, weakness, incoordination, etc., should be equated to additional loss of motion (beyond that shown clinically). Finally, the examiner should provide an opinion as to the degree to which the Veteran's lumbar spine disorder interferes with his ability to secure and follow substantially gainful employment, with specific references to any tasks or activities precluded by the disorder. The examiner should provide a comprehensive report including complete rationale for all conclusions reached. 5. The AOJ must afford the Veteran a VA examination to determine the impact of all his service-connected disabilities on his employability. All pertinent symptomatology and findings must be reported in detail. Based on the review of the claims file, the examiner must provide an opinion as to the effects of all service-connected disabilities on his ability to obtain and maintain gainful employment. 6. The AOJ must ensure that all examination reports comply with this remand and the questions presented in the examination request. If any report is deficient, it must be returned to the examiner for necessary corrective action, as appropriate. 7. Thereafter, the AOJ should readjudicate the claims remaining on appeal on the basis of all evidence of record and all applicable laws and regulations. If any determination remains unfavorable to the Veteran, he and his representative should be furnished a SSOC, which includes a summary of additional evidence submitted, and any additional applicable laws and regulations. The SSOC must provide reasons and bases for the decisions reached. Thereafter, the Veteran and his representative should be given the opportunity to respond. After the above actions have been accomplished, the case should be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs