Citation Nr: 1129062 Decision Date: 08/08/11 Archive Date: 08/16/11 DOCKET NO. 09-13 769 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to a disability rating higher than 10 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating higher than 20 percent for service-connected traumatic arthritis of the back. 3. Entitlement to a disability rating higher than 10 percent for service-connected peripheral neuropathy affecting the bilateral upper and lower extremities. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to June 1989. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions dated May 2008 and February 2009 issued by the Department of Veterans Affairs (VA) Regional Office (RO) above. FINDINGS OF FACT 1. The most competent, credible, and probative evidence of record reflects that the Veteran's service-connected PTSD results in a social impairment due to chronic sleep impairment, occasional disturbances in mood, self-isolation, and mild impaired impulse control. The Veteran has good personal hygiene and is shown to have normal speech, normal thought process and content, normal cognitive functioning, intact memory, and good insight and judgment. 2. The preponderance of the evidence reflects that the Veteran's service-connected traumatic arthritis of the back is manifested by pain and occasional tenderness to palpation in the bilateral lumbar paraspinal muscles. The Veteran is able to demonstrate flexion to no less than 60 degrees, with occasional complaints of pain, and extension, bilateral lateral rotation, and bilateral lateral flexion to 30 degrees, without any pain. Additional functional limitation due to pain, fatigue, weakness, lack of endurance, and incoordination is not shown. 3. The preponderance of the evidence reflects that the Veteran's service-connected peripheral neuropathy affecting the bilateral upper extremities is manifested by subjective complaints of progressive numbness and slight tingling in his hands. The objective evidence reflects that monofilament test reveals loss of feeling on the ventral aspect of the Veteran's bilateral hands, while sensation is maintained in the dorsal aspect of the hands. There is also evidence of decreased sensation to light touch, vibration, and temperature examination. The Veteran's hands appear normal, there is no evidence of tenderness to palpation, painful motion, or of muscle atrophy or wasting. The bilateral upper extremity disability does not interfere with the Veteran's daily activities. 4. The preponderance of the evidence reflects that the Veteran's service-connected peripheral neuropathy affecting the bilateral lower extremities is manifested by subjective complaints of progressive numbness and slight tingling in his feet. The objective evidence reflects that monofilament testing has revealed loss of feeling on the plantar aspect of both feet, while the dorsal aspect of the feet maintained sensation, without any lesions. There is also evidence of decreased sensation to light touch, vibration, and temperature examination to both feet. Objective evidence also reveals that there is sensorimotor polyneuropathy described as glove-stocking distribution of numbness, sensory loss, dysthesia, and night time pain. The bilateral lower extremity disability does not interfere with the Veteran's daily activities. CONCLUSIONS OF LAW 1. The schedular criteria for a 30 percent rating for service-connected posttraumatic stress disorder have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2010). 2. The schedular criteria for a disability rating higher than 20 percent for service-connected traumatic arthritis of the back have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.20, 4.84a, Diagnostic Code 5242 (2010). 3. The schedular criteria for a higher disability rating for service-connected peripheral neuropathy affecting the bilateral upper and lower extremities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.20, 4.84a, Diagnostic Codes 8615, 8620 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155 (West 2002). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2010). In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. § 4.2. An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Also, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). PTSD Service connection for PTSD was established in June 2005, and the RO assigned a 10 percent disability rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, effective April 2004. In October 2007, the Veteran filed a claim seeking an increased rating for his service-connected PTSD disability. Under the rating criteria, PTSD is evaluated under a general rating formula for mental disorders. See 38 C.F.R. § 4.130, DC 9411 (2010). The Veteran is currently rated as 10 percent disabled under the general rating formula. A 10 percent rating is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as : depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, direction, recent events). A 50 percent rating is warranted where there is an occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The Global Assessment of Functioning is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A score of 61 to 70 is defined as indicating some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). Review of the pertinent evidence reveals that the Veteran's service-connected PTSD is manifested by sleep disturbances, recurrent memories about his Vietnam experiences, and self-isolation. At the January 2008 VA examination, the Veteran reported having frequent sleep difficulties, including nightmares two to three times a week and waking up several times a night. He reported having difficulty controlling his temper, which he reported is primarily a problem when dealing with his wife. He reported that he only communicates with his wife and daughters, as he feels estranged from others and spends most of his time alone. He also reported that he has lost interest in almost all of his hobbies and that he only goes fishing or hunting once or twice a year. At the January 2008 examination, the Veteran had good personal hygiene and was oriented to time, person, and place. He demonstrated regular rate and volume with his speech and the examiner noted that his thought process and communication were logical. The Veteran denied having any delusions or hallucinations, suicidal or homicidal ideations, memory loss or impairment, panic attacks, or depression or depressed mood. The examiner also noted that there was no evidence of obsessional or ritualistic behavior or impaired impulse control, providing some evidence against this claim. The evidence contained in the VA treatment records is consistent with the findings of the January 2008 VA examination. Indeed, the treatment records reflect that the Veteran has a sleep impairment, which results in his sleeping six to eight hours a night and experiencing nightmares two to three times a week. Otherwise, the Veteran is shown as fully oriented and consistently described as neatly and casually dressed and groomed. His mood is variously described as depressed and euthymic, while his affect is consistently described as congruent with his mood, with one notation that he is easily tearful. The VA treatment records show that the Veteran's speech is normal in rate, volume, and pressure, and that his thought process is normal, coherent, and goal-directed. The evidence reflects that his thought content does not include any delusions or audio or visual hallucinations and the Veteran consistently denied having suicidal or homicidal ideations or thoughts. In addition, the treatment records do not contain any evidence of memory loss or impairment and his judgment and insight are described as good. See VA treatment records. Based on the foregoing, the Board finds that the preponderance of the evidence supports the grant of a 30 percent disability rating, but no higher, for the Veteran's service-connected PTSD. The Board finds that the evidence reflects that, despite the Veteran's PTSD, he is generally able to function satisfactorily, as reflected by his ability to maintain good personal hygiene and communicate normally. In addition, the evidence shows that the Veteran's thought content, cognitive functioning, and memory are normal and grossly intact. However, the Veteran suffers an impairment in social functioning, as the evidence shows that he self-isolates, has lost interest in his hobbies, has occasional disturbances in mood, and has difficulty controlling his temper. With respect to the specifically enumerated symptomatology contemplated for a 30 percent rating under DC 9411, the evidence shows that the Veteran has occasionally reported having a depressed mood and suffering from a chronic sleep impairment. While the evidence does not show that he also experiences anxiety, suspiciousness, panic attacks, or mild memory loss, the Board finds that his symptoms more nearly approximate the level of disability contemplated by the 30 percent rating. In making this determination, the Board finds probative that, in addition to his occasional depressed mood and chronic sleep impairment, the Veteran is also shown to have problems with impulse control, as he has consistently reported difficulty controlling his temper with his wife. While impaired impulse control is a symptom listed under the 70 percent rating, the Board finds that the Veteran's impulse control is no more than mild, as he has specifically reported that this is a problem specific to his interactions with his wife and there is no evidence that his temper has caused problems with other individuals, including co-workers or employers. In this context, the Board notes that the evidence shows the Veteran stopped working at his long-time job as a bus driver in September 2007 due to back pain, with no indication from the Veteran or the record that his service-connected PTSD caused any impairment in occupational functioning. Accordingly, the Board finds that, while the Veteran is generally shown to function satisfactorily, his PTSD results in a social impairment with occasional decrease in functioning due to occasional disturbances in mood, chronic sleep impairment, mild impaired impulse control, and self-isolation, which more nearly approximates the level of disability contemplated by the 30 percent rating under DC 9411. A rating higher than 30 percent is not supported by the preponderance of the evidence because the Veteran's symptoms do not show reduced reliability and productivity due to symptoms such as stereotyped speech, panic attacks more than once a week, difficulty understanding complex commands, memory impairment, or impaired judgment or abstract thinking. In addition, the evidence does not reflect that the Veteran's symptoms result in deficiencies in most areas due to suicidal ideation, obsessional rituals, near-continuous panic or depression, spatial disorientation, or neglect of personal appearance. Moreover, the evidence does not show that the Veteran's PTSD has resulted in a total occupational or social impairment. See DC 9411. In evaluating this claim, the Board notes that the Veteran has been consistently assigned a GAF score of 50 throughout the pendency of this claim and appeal, which denotes serious symptoms or any serious impairment in social or occupational functioning. The Board again notes that the evidence shows the Veteran has a social impairment due to his PTSD. However, in making the above determination, the Board finds probative that the Veteran has not demonstrated the majority of the symptoms listed in the rating criteria for a 50, 70, or 100 percent rating under DC 9411, or the majority of the symptoms listed in the GAF scale for serious symptoms (severe obsessional rituals, frequent shoplifting, and inability to keep a job). The Board is aware that the symptoms listed for each rating under DC 9411 and in the GAF scale are essentially examples of the type and degree of symptoms for that evaluation, and that the Veteran need not demonstrate those exact symptoms to warrant a rating higher than 30 percent. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, as discussed above, the Board finds that the preponderance of the evidence does not show the Veteran manifested symptoms that equal or more nearly approximate the criteria for a 50, 70, or 100 percent rating and, thus, the GAF scores assigned in this case are not considered reflective of the overall impairment experienced by the Veteran. The Board finds that the clinical information provided in the treatment records and January 2008 VA examination report are the most competent, credible, and probative evidence regarding the severity of the Veteran's service-connected PTSD. The Board has considered the Veteran's service-connected PTSD under all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, after careful review of the available diagnostic codes and the medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign a rating higher than the 30 percent rating assigned herein. In summary, and for the reasons and bases set forth above, the Board finds the preponderance of the evidence supports the grant of a 30 percent rating, but no higher, for service-connected PTSD. In making this determination, all reasonable doubt has been resolved in favor of the Veteran. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Back Service connection for traumatic arthritis of the back was established in January 1990, and the RO assigned a noncompensable (zero percent) disability rating pursuant to 38 C.F.R. § 4.73, DC 5010-5292, effective July 1989. In June 2003, the RO increased the Veteran's disability rating to 10 percent under DC 5010-5292, effective October 2002, and in June 2005, the RO increased his disability rating to 20 percent under DC 5242, effective April 2004. In October 2007, the Veteran filed a claim seeking an increased rating for his service-connected back disability, asserting that he was unable to cope with the pain. As noted, the Veteran is currently rated 20 percent disabled under the criteria of DC 5292, for degenerative arthritis of the spine, which is evaluated under a general rating formula for diseases and injuries of the spine. See 38 C.F.R. § 4.71a, DCs 5235 to 5343 (2010). The criteria for the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes) are as follows, in part: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: 100% Unfavorable ankylosis of the entire spine; 50% Unfavorable ankylosis of the entire thoracolumbar spine; 40% Forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; 20% Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 10% Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or the 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 in the loss of 50 percent or more of height. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 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. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic 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 Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, DCs 5235 to 5243 (2010). The pertinent evidence of record reflects that the Veteran's service-connected back disability is primarily manifested by low back pain, which the Veteran has reported prevents him from working, running, or lifting heavy items. The Veteran is, however, able to walk up to three miles a day, although his ability to walk longer distances has decreased somewhat during the pendency of this claim and appeal. There has been evidence of occasional tenderness to palpation in the bilateral lumbar paraspinal muscles; however, the Veteran has never lodged complaints of radiating pain, swelling, bowel or bladder changes associated with his service-connected back disability. The evidentiary record contains varying information regarding the Veteran's range of motion. At a January 2008 VA general medical examination, the Veteran demonstrated flexion to 80 degrees, with pain at 80 degrees, and extension, bilateral lateral rotation, and bilateral lateral flexion to 30 degrees, without any pain. The VA examiner noted that there was no loss of motion upon repetition due to pain, weakness, fatigability, or loss of endurance. The examiner also noted that there was no evidence of muscle spasm, muscle atrophy, or ankylosis. Otherwise, a June 2008 VA treatment record reflects that the Veteran was able to demonstrate flexion to 60 degrees and rotation to 40 degrees bilaterally. Based on the foregoing, the Board finds the preponderance of the evidence does not support the grant of a disability rating higher than 20 percent for the Veteran's service-connected back disability. While the evidence shows the Veteran experiences limited and occasionally painful motion in his back, the evidence does not show that his range of motion is limited to 30 degrees or less in flexion or that he experiences ankylosis of any kind in his thoracolumbar spine. Indeed, the evidence shows that the Veteran is able to demonstrate movement in all planes of excursion in his back and there is no evidence of difficulty walking due to limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphramic respiration, or any of the other symptoms consistent with ankylosis. 38 C.F.R. §§ 4.40 and 4.45 and the decision in DeLuca v. Brown, 8 Vet. App. 202 (1995), require the Board to consider the Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using the limitation-of-motion diagnostic codes. Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). However, under Spurgeon v. Brown, 10 Vet. App. 194 (1997), the Board is not required to assign a separate rating for pain. The Board has also considered the Veteran's service-connected back disability under DeLuca, supra. However, the preponderance of the evidence does not reflect that the Veteran experiences any additional functional limitation due to pain, weakness, fatigability, or loss of endurance at any time during the pendency of this claim or appeal. In addition, the evidence shows that the Veteran only lodged complaints of pain when he reached the extremes of flexion and repetition did not reveal any additional loss of function due to pain, weakness, fatigability, or lack of endurance. Therefore, the Board finds that there is no additional functional impairment due to pain for which a rating higher than 20 percent may be granted. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. In evaluating this claim, the Board has considered the assertion recently made by the Veteran's representative that, if an increased rating is not granted, the claim should be remanded for a new VA examination. The Veteran's representative argued that a March 2009 letter from the Veteran's physician shows that the Veteran's back disability has worsened since the last VA examination in January 2008, as it reflects that he had a back pain exacerbation. The Board has carefully reviewed the representative's assertion and the March 2009 letter submitted by Dr. R.G.; however, the Board finds that a new VA examination is not warranted because neither the Veteran nor the letter from Dr. R.G. provide any specific information as to how the Veteran's back disability has worsened. Dr. R.G. merely stated that the Veteran was seen for an exacerbation of back pain in February 2009 and was retreated with Aleve, with no indication that the back pain resulted in any additional or increased functional limitation, including muscle spasms or decreased range of motion. In addition, the Board notes that the evidentiary record contains treatment records signed by Dr. R.G. and the only notation of treatment in February 2009 was rendered for left knee pain, for which the Veteran was given Aleve. Therefore, the Board finds that there is no credible evidence of increased back symptomatology which prompts the need for a new VA examination. In summary, and for the reasons and bases set forth above, the Board finds the preponderance of the evidence is against the grant of a disability rating higher than 20 percent rating for service-connected traumatic arthritis of the back. Because the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application and his claim is denied. See Gilbert, supra. Peripheral Neuropathy Service connection for peripheral neuropathy affecting the bilateral upper and lower extremities was established in February 2009, and the RO assigned a noncompensable disability rating under DC 8516 for the bilateral upper extremity disabilities and a noncompensable disability rating under DC 8520 for the bilateral lower extremity disabilities, each effective from October 2007. The Veteran disagreed with the disability rating assigned to his service-connected peripheral neuropathy disabilities and, in June 2010, the RO increased his disability ratings to 10 percent under DC 8615 for the upper extremities and DC 8620 for the lower extremities, effective October 2007. The Veteran was advised of the grant of the increased ratings in June 2010, but he did not withdraw his claim for an increased rating. Therefore, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993) (the veteran will generally be presumed to be seeking the highest rating available, and it follows that a partial grant of an increased rating does not terminate an appeal). In support of his claim, the Veteran has specifically asserted that he believes he suffers from moderate incomplete paralysis in his extremities due to his service-connected disabilities. As noted, the Veteran is currently rated 10 percent disabling for his service-connected peripheral neuropathy disabilities under DCs 8615 and 8620, which provide the rating criteria for neuritis of the median and sciatic nerve, respectively. Under DC 8615, neuritis of the median nerve warrants a 10 percent rating for mild incomplete paralysis. Moderate incomplete paralysis warrants a 20 percent rating when affecting the minor extremity and a 30 percent rating for the major extremity. Severe incomplete paralysis warrants a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. Complete paralysis warrants a 60 percent rating for the minor extremity and a 70 percent rating for the major extremity. Complete paralysis is contemplated to include the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of the index finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right ankles to palm; flexion of wrist weakened; pain with trophic disturbances. Under DC 8620, neuritis of the sciatic nerve warrants a 10 percent rating if mild and incomplete, a 20 percent rating if moderate and incomplete, a 40 percent rating if moderately severe and incomplete, and a 60 percent rating if severe, with marked muscular atrophy. Complete paralysis of the sciatic nerve warrants an 80 percent rating and is contemplated to include the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. See 38 C.F.R. § 4.124a. When a partial disability results from disease or injury of both arms, or of both legs, or of paired skeletal muscles, the ratings for the disabilities of the right and left sides will be combined as usual, and 10 percent of this value will be added (i.e., not combined) before proceeding with further combinations, or converting to degree of disability. 38 C.F.R. § 4.26. With respect to the Veteran's upper extremity peripheral neuropathy, the pertinent evidence reflects that the Veteran has complained of progressive numbness and slight tingling in his hands. The objective evidence reflects that, in December 2007, the monofilament test revealed loss of feeling on the ventral aspect of the Veteran's bilateral hands; however, sensation is maintained in the dorsal aspect of the hands. Otherwise, the Veteran's hands appeared normal, there was no tenderness to palpation, and there was no pain with range of motion. At the April 2010 VA examination, objective evaluation revealed neuritis in the hands with no muscle atrophy or wasting. Evaluation also revealed decreased sensation to light touch, vibration, temperature, and monofilament exam to both hands, and the VA examiner noted that the Veteran's bilateral hand disability does not interfere with his daily activities. The pertinent evidence reflects that the Veteran has lodged similar complaints regarding the neurologic condition affecting his bilateral lower extremities, as he has complained of progressive numbness and slight tingling in his feet. The objective evidence is also similar, as monofilament testing in December 2007 revealed loss of feeling on the plantar aspect of both feet, while the dorsal aspect of the feet maintained sensation and no lesions were noted on the feet, except for loss pigment. At the April 2010 VA examination, the examiner noted there was sensorimotor polyneuropathy described as glove-stocking distribution of numbness, sensory loss, dysthesia, and night time pain. The examiner also noted there was decreased sensation to light touch, vibration, temperature, and monofilament exam to both feet, and that the Veteran's bilateral foot disability does not interfere with his daily activities. Based on the foregoing, the Board finds that the preponderance of the evidence does not support the grant of a disability rating higher than 10 percent for the Veteran's service-connected bilateral upper and lower extremity peripheral neuropathy disabilities. Indeed, the evidence shows that the Veteran's upper and lower extremity neurological disabilities are wholly sensory, without any evidence of motor or other functional impairment related thereto. As noted, while the evidence shows that the Veteran experiences decreased sensation in his hands and feet, there is no evidence of decreased motion or other functional impairment in the hands or feet. The law specifically provides that a wholly sensory impairment warrants a mild, or at most, moderate rating. However, the Board finds that the Veteran's service-connected bilateral upper and lower extremity neurological disabilities are no more than mild, as there is evidence showing that the sensory impairment only affects the plantar and ventral aspects of the bilateral feet and hands, with no evidence of decreased sensation in the dorsal aspect of the feet and hands. Therefore, the Board finds the evidence does not show symptoms that more nearly approximate the level of disability contemplated by the rating criteria for moderate or severe incomplete paralysis affecting the median and sciatic nerves; nor does the evidence show symptoms of complete paralysis of the median and sciatic nerves. The Board finds that the post-service medical records provide highly probative evidence against this claim, indicating the mild nature of the problem. Therefore, based on the foregoing reasons and bases, the Board finds that the preponderance of the evidence is against the grant of a disability rating higher than 10 percent for the Veteran's service-connected bilateral upper and lower extremity peripheral neuropathy disability. Because the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application and the Veteran's claim is denied. See Gilbert, supra. Duties 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. 2009); 38 C.F.R. § 3.159, 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1), as amended, 73 Fed. Reg. 23,353 (April 30, 2008). This notice must be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); 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). The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). For an increased-compensation claim, the VCAA requirement is generic notice, that is, notice that informs the claimant of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In this case, the VCAA duty to notify was satisfied as to all claims on appeal by way of a letter sent to the Veteran in November 2007 that fully addressed all required notice elements. The letter informed the Veteran of what evidence was required to substantiate his service connection and increased rating claims, of the Veteran's and VA's respective duties for obtaining evidence, and of how disability ratings and effective dates are assigned. With respect to the claims involving the Veteran's bilateral upper and lower extremity peripheral neuropathy, the Board notes that the Veteran is challenging the initial rating assigned following the grant of service connection. In Dingess, supra, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided to the Veteran in November 2007 (before service connection was granted) was legally sufficient, VA's duty to notify in this case has been satisfied. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims on appeal. The RO has obtained the Veteran's service treatment records, as well as all post-service treatment records identified by the Veteran and the evidentiary record. Significantly, it appears that all obtainable evidence identified by the Veteran relative to his claim 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, which would need to be obtained for a fair disposition of this appeal. The Veteran was also afforded VA examinations in January 2008 and April 2010, and there is no indication or allegation that the VA examinations conducted in conjunction with this appeal were not adequate to appropriately evaluate the Veteran's disabilities. ORDER A 30 percent rating for service-connected PTSD is granted. Entitlement to a disability rating higher than 20 percent for service-connected traumatic arthritis is denied. Entitlement to disability ratings higher than 10 percent for service-connected peripheral neuropathy affecting the bilateral upper and lower extremities is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs