Citation Nr: 1144721 Decision Date: 12/07/11 Archive Date: 12/14/11 DOCKET NO. 08-02 624 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an initial rating in excess of 10 percent for lumbar strain. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1996 to May 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which granted service connection for a lumbar spine disability and awarded a 10 percent rating, effective May 28, 2005. The Veteran appealed the assigned rating. In July 2009, the claims folder was transferred and is now within the jurisdiction of the RO in Baltimore, Maryland. FINDINGS OF FACT 1. The Veteran failed to report, without good cause, for a scheduled January 2011 VA examination, which was deemed necessary to determine the current severity of his lumbar strain. 2. During a June 2010 VA examination, the Veteran's service-connected lumbar strain was manifest by 75 degrees of forward flexion with an approximate 15 degrees loss of functional range of motion, and a combined range of motion of 225 degrees. 3. The Veteran denied any complication or changes to his lumbar spine disability since the June 2010 VA examination; therefore, a private independent medical evaluation dated in June 2010 is not credible. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 10 percent for lumbar strain have not been met. 38 U.S.C.A. §§ 1155, 5701(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1-4.7, 4.71a, Diagnostic Code 5237 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the Veteran's claim for service connection for a low back disability was submitted in November 2005. In August 2006, the RO granted service connection for lumbar strain and assigned a 10 percent rating which is the subject of this appeal. Thus, the Veteran's claim for a higher evaluation is a downstream issue, which was initiated by a notice of disagreement. The Court has held that, as in this case, once a notice of disagreement from a decision establishing service connection and assigning the rating and effective date has been filed, the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements...." Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Hence, there is no duty to provide additional notice in this case. However, via December 2005 and May 2006 letters, the Veteran was advised of the requirements of VCAA, pertaining to his duties and the duties and obligations of VA in assisting him to complete his claim. The Veteran failed to report for a January 2011 VA spine examination. He was notified pursuant to December 2010 correspondence that it was his responsibility to report for the examination and to cooperate in the development of his case, and that consequences of failure to report for VA examination without good cause may include denial of the claim. A January 2011 VA examination note documented the Veteran's refusal to report to his examination. He stated that he "had this examination just done 6-months ago" and he did not want to go through the evaluation again. He reported that he was not appealing his 10 percent rating for his lumbar spine disability and denied any complications or changes since his last VA examination in June 2010. In August 2011, the RO informed the Veteran that they were notified of his refusal to report to the scheduled VA spine examination, and his assertion that he was not appealing the assigned 10 percent rating for his service-connected lumbar spine disability. The RO notified the Veteran that if he would like to withdraw his appeal for an initial rating in excess of 10 percent for his lumbar spine disability, he needed to notify the RO in writing within 30 days. No response was received; therefore, the appeal remains before the Board. Pursuant to 38 C.F.R. § 3.655, when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination, and a claimant, without good cause, fails to report for such examination or reexamination, scheduled in conjunction with a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655(b) (2011). In this regard, the Court has held, "The 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." See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). All pertinent development has been undertaken, examinations have been performed, and all available evidence has been obtained in this case. Therefore, no further action is necessary for compliance with the VCAA. Further attempts to obtain additional evidence would be futile. The Board finds the available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to move forward with the claim would not cause any prejudice to the appellant. Merits of the Claim Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. §§ 4.2, 4.41. An evaluation of the level of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. In evaluating 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. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability so that actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on motion. See 38 C.F.R. §§ 4.10 , 4.40, 4.45, 4.49; DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). The Court has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, the analysis in the following matter is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the appeal. The Veteran must not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Ratings shall be based, as far as practicable, upon the average impairments of earning capacity; however, the Secretary shall, from time to time, readjust this schedule of ratings in accordance with experience. To accord justice in an exceptional case in which the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Veteran is claiming entitlement to an initial rating in excess of 10 percent for lumbar strain. As an initial matter, the Board observes that the Veteran is currently assigned a 10-percent rating under Diagnostic Code 5237 for lumbosacral strain. Under the applicable law, the Board finds that a staged rating analysis is appropriate in this case. A 10-percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, or with muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Code 5237. A 20-percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or with 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 assigned when forward flexion of the thoracolumbar spine is 30 degrees or less or when there is favorable ankylosis of the entire thoracolumbar spine. Id. A 50-percent evaluation is assigned when there is unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100-percent evaluation is assigned when there is unfavorable anklyosis of the entire spine. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 45 degrees, bilateral rotation is zero to 30 degrees, and lateral flexion to either side is zero to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note (2) (2011); see also 38 C.F.R. § 4.71a, Plate V (2011). 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 ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). Each range of motion measurement is rounded to the nearest five degrees. Id. at Note (4). The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note (2). The notes to the revised rating formula for diseases and injuries to the spine state that any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2011). Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table) (2011). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10-percent rating is awarded for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20-percent rating is awarded for disability with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40-percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. A maximum 60-percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic 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 neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 38 C.F.R. § 4.71a (2011). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). Service treatment records include complaints of low back pain, muscle strain, and muscle spasm in July 1998. In a March 2005 separation examination report, the examining medical officer noted the Veteran's degenerative joint disease of the spine resolved after inactivity. He indicated the pain "may be chronic or occasional," but determined that no further evaluation was necessary. In a November 2005 statement, the Veteran reported his low back caused constant pain. He noted tenderness; sharp, throbbing pain after sudden movements; and stiffness after sitting for long periods of time. During a May 2006 VA QTC spine examination, the Veteran acknowledged stiffness, specifically when he woke in the morning and after periods of inactivity, and weakness. The Veteran denied pain symptoms and incapacitation; however the examiner noted the Veteran had difficulty sleeping due to pain. He denied urinary and fecal incontinence and leg or foot weakness. The Veteran reported he was able to brush his teeth, take a shower, vacuum, drive a car, cook, climb stairs, dress himself, take out the trash, walk, shop, perform gardening activities, and push a lawnmower. He was employed as an investigator. Examination of the thoracolumbar spine revealed no evidence of radiating pain on movement, muscle spasm, or tenderness. Straight leg testing was negative bilaterally. There was no ankylosis of the lumbar spine. There were no signs of intervertebral disc syndrome. Range of motion was as follows: MOVEMENT ACTUAL DEGREE PAIN OCCURS NORMAL* Forward Flexion 65° 65° 90° Backward Extension 30° N/A 30° Right Lateral Flexion 25° 25° 30° Left Lateral Flexion 30° N/A 30° Right Lateral Rotation 25° 25° 30° Left Lateral Rotation 30° 30° 30° *see 38 C.F.R. § 4.71a, Plate 5 (2010) The examiner noted function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Lumbar spine x-ray findings were within normal limits with no radiographic abnormality; however, the interpreting physician noted there was straightening of the lumbar spine which may have been due to the Veteran's position during the x-ray or muscle spasm. The diagnosis was chronic ligamentous lumbar spine strain with chronic low back pain and decreased range of motion. In a statement received by VA in June 2006, the Veteran reported his low back pain started in his upper back and moved diagonally to his low back. He indicated that he took extra strength over-the-counter pain relievers four days per week to alleviate his pain. He related that he was unable to work out due to his back pain and symptoms from other service-connected disabilities. In a May 2008 independent medical evaluation, Craig N. Bash, M.D., reported that he reviewed the Veteran's medical records and performed a lumbar spine examination. Dr. Bash noted the Veteran had pain on all movements. Range of motion was as follows: MOVEMENT ACTUAL NORMAL* Forward Flexion 45° 90° Backward Extension 10° 30° Right Lateral Flexion 25° 30° Left Lateral Flexion 25° 30° Right Lateral Rotation 25° 30° Left Lateral Rotation 25° 30° There was pain on palpation of the L4-5 disc space. The Veteran reported daily paraspinal muscle spasms and pain that radiated down his right posterior leg. The diagnosis was advanced degenerative disc/facet problems. Dr. Bash noted the Veteran lost his ability to run or squat, and had reduced reflexes, spasms, and pain consistent with sciatica. The physician stated, "My exam shows more sever[e] spine disease than does the exam documented in the 2006 rating decision suggesting that the [Veteran's] spine [has] become more problematic over time. [He] states that he feels that his spine is becoming less functional." In a January 2007 notice of disagreement, the Veteran contended his low back disability was characterized by chronic, persistent pain, discomfort, and limitation of motion. During a June 2010 VA spine examination, the Veteran reported progressive worsening of his low back disability since service. He denied fatigue, decreased motion, stiffness, weakness, and spasms. He acknowledged constant pain across his low back. He rated the pain as 3 out of 10 in severity. He noted daily flare-ups lasting 30 minutes each that were moderate in severity. Routine activities precipitated the flare-ups, and aspirin and stretching alleviated the flare-ups. He related that he was limited to walking a few hundred yards. He reported five incapacitating episodes, which each lasted one day in duration; however, bed rest was not prescribed by medical personnel. Upon examination, the Veteran's gait was normal. No gibbus, kyphosis, list, lumbar flattening, lumbar lordosis, scoliosis, spasm, atrophy, guarding, pain with motion, tenderness, or weakness was observed. Range of motion was as follows: MOVEMENT ACTUAL NORMAL* Forward Flexion 75° 90° Backward Extension 30° 30° Right Lateral Flexion 30° 30° Left Lateral Flexion 30° 30° Right Lateral Rotation 30° 30° Left Lateral Rotation 30° 30° There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions of range of motion. X-rays revealed a normal lumbar spine. There was no evidence of vertebral fractures. The examining physician opined that the incapacitating episodes described by the Veteran were not due to intervertebral disc syndrome. The diagnosis was low back strain. The Veteran reported he was employed as a criminal investigator in a sedentary, full-time capacity. He reported 8 days of lost work in the past 12 month period for his low back disability and other ailments and disorders. The examiner noted no significant effects on the Veteran's usual occupation. She noted severe effects on the Veteran's performance of recreational activities, including preventing exercise and participation in sports; mild effects on the Veteran's ability to perform chores; and no effects on his ability to shop, travel, feed himself, bathe, dress, use the restroom, and groom himself. In a June 2010 independent medical evaluation, Dr. Bash reported the Veteran was unable to rise from a chair or the floor without using a grapple device or support. Lumbar spine range of motion was as follows: MOVEMENT ACTUAL NORMAL* Forward Flexion 50° 90° Backward Extension 10° 30° Right Lateral Flexion 25° 30° Left Lateral Flexion 25° 30° Right Lateral Rotation 25° 30° Left Lateral Rotation 25° 30° Straight leg testing was positive bilaterally. The Veteran described daily low back paraspinal and leg muscle spasms, and stated he was unable to run or climb stairs due to his back and service-connected knee pain. Dr. Bash noted subtle mild degenerative changes on x-ray images of the lumbar spine. In a January 2011 VA examination note, the Veteran refused evaluation of his service-connected lumbar spine disability and denied any complication or change since his last VA examination in June 2010. The Veteran's service-connected back disability is currently rated as 10 percent disabling. According to the pertinent part of the rating schedule, a 10 percent rating is appropriate when forward flexion of the thoracolumbar spine, greater than 60 degrees, but no greater than 85 degrees; or a combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Code 5237. The evidence, reviewed above, does not reflect unfavorable ankylosis of the entire thoracolumbar spine or, as required under the current Formula for Rating Intervertebral Disc Syndrome for a higher rating, incapacitating episodes, requiring bed rest as prescribed by a physician, having a total duration of at least one week during the past twelve months. During the June 2010 VA spine examination, the Veteran reported he had incapacitating episodes; however, he was not prescribed bed rest by a physician. Under Diagnostic Code 5243, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician. Further, the June 2010 VA examining physician opined that the Veteran's reported incapacitating episodes were not due to intervertebral disc syndrome; therefore, the Formula for Rating Intervertebral Disc Syndrome due to incapacitating episodes is not for application in this case. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under Diagnostic Code 5237, a higher rating, 20 percent rating, is not warranted unless forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees, or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphyosis. 38 C.F.R. § 4.71a, Diagnostic Code 5237. VA examinations in May 2006 and and June 2010 recorded forward flexion of the lumbar spine to 65 degrees and 75 degrees, respectively. In addition, the May 2006 VA examiner reported no evidence of muscle spasm, despite an x-ray finding of straightening of the lumbar spine which the interpreting physician opined may have been due to the Veteran's position during the x-ray or muscle spasm. Further, the June 2010 VA examiner observed the Veteran ambulated with a normal gait, and there was no evidence of muscle spasm, guarding, scoliosis, lumbar lordosis, or kyphosis. The Veteran also expressly denied muscle spasms. The results of the May 2006 and June 2010 VA examinations reflect that the Veteran's symptoms remain representative of a 10 percent rating. However, Dr. Bash's May 2008 and June 2010 independent medical evaluations suggest that a higher rating is warranted. Forward flexion of the lumbar spine was recorded to 45 degrees and 50 degrees, respectively. During the private examinations, the Veteran reported daily paraspinal muscle spasms; however, as noted above, the Veteran denied muscle spasms during his June 2010 VA examination and neither the May 2006 nor the June 2010 VA examiners found objective evidence of muscle spasms. The Board finds that Dr. Bash's reports of muscle spasms have limited probative value because they are merely a recitation of the Veteran's self-reported and unsubstantiated history. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (a bare transcription of lay history is not transformed into medical evidence simply because it was transcribed by a medical professional). With respect to the apparent discrepancy between the VA examiners' range of motion measurements and Dr. Bash's range of motion measurements, the Board has determined that the VA examiners' examinations are more probative. After his June 2010 examination performed by Dr. Bash, the Veteran refused evaluation of his service-connected lumbar spine disability in January 2011 and denied any complications or changes since his June 2010 VA examination (which occurred approximately three weeks before Dr. Bash's June 2010 examination). This calls into question the reliability of Dr. Bash's findings. The Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (holding that interest in the outcome of a proceeding may affect the credibility of testimony). Additionally, as discussed above, pursuant to 38 C.F.R. § 3.655, when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination, and a claimant, without good cause, fails to report for such examination or reexamination, scheduled in conjunction with a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655(b) (2011). As such, the Board finds that the Veteran is adequately compensated for his disability by the currently assigned 10 percent rating. The Board has also considered whether the consideration of a higher rating is appropriate based on evidence of pain, weakened movement, excess fatigability, or incoordination. See 38 C.F.R. § 4.40; DeLuca, 8 Vet. App. 202. However, under 38 C.F.R. § 4.71a , General Rating Formula for Diseases and Injuries of the Spine, disability ratings are to be assigned without regard to pain, stiffness, and aching. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, the preponderance of the evidence is against the assignment of any higher rating and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Board also has considered whether the Veteran's back disability presents an exceptional case such that the schedular evaluation is inadequate. However, the record does not reflect frequent periods of hospitalization or marked interference with employment. Throughout the appellate period, the Veteran maintained employment as an investigator and no medical professional has indicated that the back disability renders him unable to work. See Thun v. Peake, 22 Vet. App. 111 (2008). Further, the degrees of disability specified in the rating schedule are generally considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. This is another way of saying that the Veteran's existing rating assigned for his disability contemplates some employment impairment. Although his disability may interfere with his ability to work, such impairment is already contemplated by the applicable schedular criteria so that consideration of an extraschedular rating is not shown to be necessary. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating, itself, is recognition that industrial capabilities are impaired). Therefore, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Additionally, the Board has determined that referral for a TDIU rating is not warranted. TDIU is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2011). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2011) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). While the Veteran's service-connected disabilities have an impact on his functional capacity, he has not contended, and the evidence of record does not demonstrate, that his service-connected disabilities, alone, either singly or jointly, prohibit him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. At the time of the June 2010 examination, the Veteran indicated he was employed in a sedentary position as an investigator. As such, and as no physician has opined that his service-connected disabilities render him unemployable, the Board concludes that the Veteran in this case has not raised a claim of entitlement to a TDIU rating and that referral for a TDIU rating is therefore not warranted. ORDER An initial rating in excess of 10 percent for lumbar strain is denied. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs