Citation Nr: 1119276 Decision Date: 05/18/11 Archive Date: 05/26/11 DOCKET NO. 06-28 267 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a separate disability rating for radiculopathy of the left lower extremity associated with service-connected low back disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Whitehead, Associate Counsel INTRODUCTION The Veteran had service in the Army Reserves, with active duty including from July 1996 until November 1996 and from January 2003 until October 2003. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 2005 and July 2006 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In September 2008, the Veteran testified before the undersigned Veterans Law Judge during a Travel Board hearing held at the RO. A transcript of that hearing has been associated with the claims file. In March 2009, the Board remanded the case to the RO, via the Appeals Management Center (AMC), for further development and adjudicative action. In a February 2011 Supplemental Statement of the Case (SSOC), the RO/AMC affirmed the determination previously entered. The case was then returned to the Board for further appellate review. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's PTSD more closely approximates occupational and social impairment with reduced reliability and productivity. 2. The preponderance of the evidence shows that the Veteran has neurological impairments affecting her left lower extremity related to her service-connected low back disability. 3. The preponderance of the evidence shows that the Veteran's left lower extremity neurological symptomatology associated with her service-connected low back disability more closely approximates a mild incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1- 4.3, 4.7, 4.41, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a separate, 10 percent disability rating for neurological impairments of the left lower extremity associated with the service-connected low back disability have been met. 38 U.S.C.A. §§ 155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1- 4.3, 4.20, 4.124a, Diagnostic Code 8520 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCCA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010) requires VA to assist a claimant at the time he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the information and evidence necessary to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, 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 attempt to provide; and (3) that the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) the degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. However, in Shinseki v. Sanders, 129 S.Ct. 1696 (2009), the United States Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. By letters dated in November 2003, July 2004, January 2005, May 2005, and March 2010, the Veteran was notified of the information and evidence necessary to substantiate her claims. VA told the Veteran what information she needed to provide, and what information and evidence that VA would attempt to obtain. Under these circumstances, the Board finds that VA has satisfied the requirements of the VCAA. As to the issue of a higher initial disability rating for the now service-connected PTSD disability and an initial separate rating for neurological impairments associated with the service-connected low back disability, an increased rating is a "downstream" issue. Once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated. See Sutton v. Nicholson, 20 Vet. App. 419 (2006) (citing Dingess). Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. She was provided appropriate VA medical examinations. There is no indication of any additional, relevant records that the RO failed to obtain. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. Increased Initial Disability Rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, 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. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in the present case, the Board notes that the Veteran is appealing the initial assignment of a disability rating, and as such, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. Ap. 625 (1992). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the rating period on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218, F.3d 1378, 1380- 81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the instant claim. PTSD Here, the Veteran claims that her service-connected PTSD is more severe than what is reflected by the currently assigned 30 percent disability rating. The Veteran's service-connected PTSD is currently rated pursuant to the criteria set forth in Diagnostic Code 9411. Under Diagnostic Code 9411, a 50 percent disability rating is warranted when occupational and social impairment is found 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent disability 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. 38 C.F.R. § 4.130. In evaluating psychiatric disabilities, the Board has adopted the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association (DMS-IV). That manual includes a Global Assessment of Functioning (GAF) scale reflecting psychological, social and occupational functioning on a hypothetical continuum of mental illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A GAF score of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). A score of 51-60 indicates 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 peer or coworkers). A score of 61 to 70 indicates some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well with some meaningful interpersonal relationships. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association, 1994. Turing to the merits of the claim, the Veteran's service treatment records document her reports of psychiatric symptomatology. A March 2003 service treatment record includes her report of crying, feeling "jumpy," difficulty sleeping, and difficulty with concentration. She reported having interpersonal problems with members of her unit. The Veteran denied having any suicidal or homicidal ideations. She was assessed has having anxiety and was referred for a further assessment. VA treatment records dated in June and July of 2004 show that the Veteran underwent psychiatric assessments, after which she was diagnosed with PTSD. The Veteran described her military stressors, which included significant conflict and feelings of harassment from other service members. Following the stressful incidents, the Veteran stated that she experienced intrusive memories of humiliation, nightmares, insomnia, withdrawal from others, poor concentration, crying spells, a depressed mood, and anxiety. She reported having a close relationship with her mother and a circle of friends. The Veteran reported that she had been employed with a state agency for thirteen years and that she enjoyed her work. However, she felt that she was mistreated by her coworkers. She stated that she lived alone and that she enjoyed several leisure activities. On the mental status examinations, the Veteran was neat in appearance and attire. She was verbal, polite, and cooperative. Her mood and affect were described as depressed and anxious. Her speech was coherent and she was oriented in all three spheres. The Veteran's attention span and concentration were both noted to be impaired, and her retention and recent memory were defective. There was no evidence any suicidal ideations, delusions, or hallucinations. The July 2004 assessment report shows a GAF score of 45. In support of her claim, the Veteran provided a May 2005 letter from her VA treating physician, C.R., M.D. He reported that the Veteran attended the VA psychiatric clinic for treatment of her PTSD. He stated that the Veteran's depression and anxiety interfered with her sleep and that she had experienced more frequent intrusive memories. Dr. C.R. reported her GAF score as 45 and stated that the Veteran had been prescribed medication to treat her symptoms. The Veteran continued to report her psychiatric symptomatology during an August 2005 VA psychological evaluation. Her symptoms were noted to include difficulty sleeping, social withdrawal, depressed and anxious mood, crying spells, and increased agitation and altercations in interpersonal interactions. On the mental status examination, the Veteran was neatly groomed and casually dressed. Her mood and affect were depressed and her speech was within normal limits. The Veteran's attention and concentration were relatively intact, with occasional lapses in concentration. She denied any suicidal or homicidal ideations, as well as any auditory or visual hallucinations. The examination was negative for evidence of a thought disorder and her insight and judgment were fair. The Veteran reported increased paranoid ideation as a result of her in-service stressors. The examiner concluded that the Veteran's symptoms were in the moderate to severe range of depression, with a moderate to strong presence of concentration difficulties, anhedonia, loss of sexual interest, and indecisiveness. Her additional symptoms were described as mild to moderate. The examiner highlighted that the Veteran experienced PTSD symptoms, to include persistent flashbacks, heightened startle response, hypervigilance, and re-experiencing shame and rejection. He concluded that these findings suggested a significant deficit in coping with difficult situations and that the Veteran appeared to have difficulty contending with the demands of the world around her. He determined that she was prone to have frequent difficulties, particularly with interpersonal interactions. In July 2005, the Veteran underwent a VA mental disorders examination. She reported her symptoms to include depression, anxiety, a lack of trust of others, poor sleep, and intrusive memories relating to negative interpersonal experiences when she was in the military. She reported having serious interpersonal difficulties at her place of employment. The Veteran relayed to the examiner a terrifying feeling that she was being followed. Due to this, she stated that she lived with her sister. She stated that she was uncomfortable around people and reported that she was basically isolated. The Veteran appeared neat in appearance on the clinical examination. Her speech was relevant, coherent and goal directed; the examiner determined that she did not have a thought disorder. Although the Veteran was logical, she presented with a flat affect. She reported that she was forgetful at times and that she had difficulty remembering names on her job. Additionally, she reported having occasional feelings of nervousness. While she reported that she was independent with her activities of daily living, she felt that she should not live alone due to her forgetfulness. The Veteran did not evidence any hallucinations, although she demonstrated evidence of paranoia. Her GAF score was reported as 55. The Veteran's VA medical records show that she underwent a psychiatric evaluation in July 2006. She described her symptoms as a depressed mood, anxiety, poor sleep with nightmares, irritability, weight gain, easy startle response, poor concentration, difficulty with coworkers, and inability to function appropriately under constant humiliation. She denied a history of violence or any suicidal acts. On the mental status examination, she was well dressed and groomed. The Veteran speech was quiet, but coherent. She reported her mood as depressed and her affect was congruent with her mood. The Veteran was noted to be labile and anxious at times. The examination was significant for decreased concentration and poor recent memory. Her insight and judgment were good. The Veteran demonstrated a GAF score of 50. The Veteran's VA treating physician reported her psychiatric symptomatology in a letter dated in August 2007. He concluded that her condition had worsened, despite the use of medication and psychotherapy. The physician stated that the Veteran was more anxious and depressed. She was also reported to have difficulty sleeping and nightmares. Her short-term memory was poor. He stated that the Veteran had more frequent panic attacks, occurring approximately five to seven days per week and that she had mood swings. The physician described the Veteran has being very suspicious of people and withdrawn. He ultimately opined that the Veteran had great difficulty in establishing and maintaining effective work and social relationships. In a January 2008 letter, Dr. C.R. further described the Veteran's psychiatric symptomatology. He reported that she had frequent nightmares and daily panic attacks. Her recent memory and concentration were described as poor. The Veteran was noted to be very anxious and depressed. The physician reported that she had great difficulty in establishing and maintaining effective work and social relationships. He indicated that he would continue to follow her for psychotherapy and medication management. Subsequently, Dr. C.R. described the nature of her psychiatric disability in a December 2008 letter. He reported her symptoms to include severe anxiety, depression, nightmares, intrusive memories, withdrawal, poor frustration tolerance, and impaired concentration. He stated that her condition made it difficult for her to function at work, her quality of life was diminished, and that she was withdrawn from others. He opined that the Veteran's condition was related to her PTSD that she incurred during her military service. Associated with the claims file is a July 2010 letter from Dr. C.R. regarding the Veteran's her psychiatric symptomatology. Her symptoms were reported to include difficulty sleeping, nightmares, intrusive memories, depression, and anxiety. The physician stated that the Veteran was withdrawn, had poor attention, was distractible, and forgetful. He also stated that the Veteran related poorly to people and that she had a poor frustration tolerance. She was describe as being distrustful of others, liable, and hyperviligant. The physician reported her GAF score as 45. The Veteran underwent a VA PTSD examination in August 2010, at which time she reported that she continued to experience psychiatric symptomatology. The Veteran reported that she was employed and that she liked her work; she stated, however, that she had difficulty with her coworkers. She denied missing any days from work due to her psychiatric disability. The Veteran reported that she lived alone and was close with only one of her seven siblings. The examiner noted that the Veteran treated her psychiatric symptoms with prescription medication. Her subjective complaints included bereavement related to her mother's death, self-consciousness of a skin condition, and complaints of mistreatment at work. She presented with occasional feelings of a depressed mood, but she reported that her mood was "generally okay." The Veteran reported having difficulty with insomnia, decreased concentration, and poor attention. She denied having any suicidal ideations. The subjective complaints associated with the Veteran's PTSD were reported to include the following: intrusive thoughts of military-related incidents; nightmares; becoming distracted by recollections of the stressful event; feelings of detachment from others; avoidance behaviors; restricted affect, irritability, difficulty concentrating; hypervigilance; exaggerated startle response to loud noises; anxiety when in a group of other people; and paranoid thinking. On the mental status examination, the Veteran was appropriate in appearance and cooperative. She was withdrawn and maintained poor eye contact. Her motor functioning was unremarkable. Although she reported that her mood was "not so good" at the time of the examination, she stated that her mood was stable. The Veteran's affect was constricted, but appropriate to content. She became tearful when discussing her mother. The Veteran's speech was within normal limits, although she generally mumbled and was quiet at times. Her thoughts were well organized and generally logical, although her content was noted to be paranoid. There were no gross impairments in her thought process or communication. The Veteran denied having any suicidal or homicidal ideations, or any auditory or visual hallucinations. She complained of problems with recent memory, poor concentration, and poor attention. Her insight and judgment were described as fair. The examination revealed a GAF score of 51. Based on the results of the examination and a review of the claims file, the examiner confirmed the diagnosis of PTSD. The examiner opined that the impact of the psychiatric symptoms on the Veteran's functioning appeared to be moderate in that her symptoms contributed to her mistrustfulness and suspiciousness of others, and avoidance of others. She further noted that the Veteran had few and poor relationships that appeared to be due, in part, to her anxiety that others will harm her, which seemed to be directly related to in-service trauma. The examiner concluded that the Veteran's psychiatric symptomatology was of a moderate severity. She stated that these symptoms affected her social functioning in that she only had one close confidant, which was her sister. She noted that the Veteran denied having any friends and that she had ongoing and frequent conflicts with coworkers. The Veteran denied that her occupational functioning in terms of productivity or performance was impacted by her psychiatric condition. The Veteran's VA medical records dated from 8/04 to February 2010 show treatment for her psychiatric symptomatology. Overall, these records document her psychiatric symptoms to include the following: difficulty sleeping, anxiety; intrusive thoughts; mild depression; withdrawal; flashbacks; poor concentration; poor attention span; panic attacks; poor memory; hyperarousal; suspiciousness; avoidance behaviors; difficulty with work relationships. Of particular note is a July 2005 treatment record, which shows that the Veteran's GAF score was 51. These records are negative for reports of suicidal or homicidal ideations. Analysis Based on review of the foregoing, the Board finds that the evidence of record is probative of a PTSD disability picture that more nearly approximates the criteria for a 50 percent disability rating. Overall, the evidence dated throughout the pendency of the appeal shows that the Veteran's psychiatric disability has primarily been manifested by evidence of occupational and social impairments with reduced reliability and productivity due to such symptoms as: disturbances of mood and motivation; depression; anxiety occurring multiple times per week; increased irritability; sleep disturbances; poor concentration and attention; short-term memory impairments; withdrawal; flashbacks; intrusive thoughts; paranoid thoughts; difficulty with work relationships; and difficulty establishing and maintaining effective work and social relationships. Her GAF score throughout the appeal has ranged from 45 to 55, which is overall indicative of serious to moderate impairments in social and occupational functioning. The Board acknowledges that the evidence when viewed in its entirety does not show evidence of circumstantial or stereotyped speech or impairments in understanding or abstract thinking. However, the Veteran's symptoms overall are significant enough to affect her daily activities to such an extent that she generally meets the diagnostic criteria for a 50 percent disability rating under 4.130, Diagnostic Code 9411. Therefore, resolving all reasonable doubt in the Veteran's favor, the Veteran's social impairments more closely approximates the criteria for a 50 percent evaluation. In this regard, the Board finds probative the opinions from the Veteran's VA treating physician, Dr. C.R., and VA examiners. In this regard, both the August 2005 and August 2010 VA examiners collectively determined that the severity of the Veteran's psychiatric symptomatology ranged from moderate to severe. Moreover, the August 2005 physician concluded that the Veteran had significant deficits in coping with difficult situations. Similarly, Dr. C.R. reported in his January 2008 and December 2008 letters that the Veteran had great difficulty establishing and maintaining effective work and social relationships and that her condition made it difficult for her to function at work. Given that these opinions are based upon the Veteran's treatment history with the physicians and clinical assessments of the Veteran, the opinions are found to carry significant probative weight. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). However, the Board finds that the preponderance of the evidence does not show that the Veteran's depression more closely approximates the criteria for the next-higher 70 percent disability rating during this time period. While the August 2005 VA physician noted that the Veteran had difficulty coping with stressful situations, adapting to stressful situations, the evidence, overall, does not show that a 70 percent disability rating is warranted. In this regard, the evidence is entirely negative for reports of suicidal or homicidal ideations, participation in obsessional rituals that interfere with the Veteran's routine activities, or evidence of spatial disorientation. While the Veteran's disorder is manifested by depression and anxiety, there is no objective evidence that indicates she has near-continuous panic or depression affecting here ability to function independently, appropriately, and effectively. Indeed, the Veteran is independent with activities of daily living and has maintained employment throughout the period on appeal. Moreover, there is no objective evidence that the Veteran has neglected her personal appearance and hygiene, as all of the medical evidence illustrates that she was adequate in her appearance and dress. As noted above, both the August 2005 and August 2010 VA physician determined, after clinical assessments of the Veteran, that severity of her symptoms ranged from moderate to severe. Essentially, the evidence of record does not support a finding that the Veteran's PTSD more closely approximates occupational and social impairments with deficiencies in most areas to warrant the next-higher 70 percent rating. The Board has considered the Veteran's statements as to the nature and severity of her PTSD symptomatology. The Veteran is certainly competent to report that her symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must only consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). To the extent that the Veteran argues or suggests that the clinical data supports an increased evaluation or that the rating criteria should not be employed, she is not competent to make such an assertion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (holding that a witness must be competent in order for his statements or testimony to be probative as to the facts under consideration). Finally, the Board has considered whether the Veteran's claim warrant referral to the Chief Benefits Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321. In Thun v. Peake, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. As has been explained fully herein, the Board finds that the disability rating assigned herein for the Veteran's PTSD contemplates the level of impairment reported by the Veteran, and there is no aspect of her disability that is not contemplated by the schedular criteria. Indeed, while higher ratings are available for the Veteran's disability, her symptomatology simply does not meet the criteria for a higher rating during the period currently on appeal. For these reasons, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321 is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). In sum, the evidence of record shows that the Veteran's PTSD warrants a disability rating of 50 percent, but no higher, from the effective date of service connection. As there appears to be no identifiable period on appeal during which this disability manifested symptoms meriting a disability rating in excess of what has been assigned herein, staged ratings are not warranted. See Fenderson, 12 Vet. App. at 119. A Separate Disability Rating for Neurological Impairments of the Left Lower Extremity Here, the Veteran seeks a separate disability rating for neurological impairments of the left lower extremity due to her low back disability. The Veteran is currently service connected for a low back disability, effective from October 2, 2003. Pursuant to regulation, any associated objective neurologic abnormalities, including, but not limited to, bladder or bowel impairment, are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Note (1) of 38 C.F.R. § 4.71a, Diagnostic Code 5237 provides that any associated objective neurological abnormalities associated with a lumbosacral strain should be evaluated separately, under an appropriate diagnostic code. Radiculopathy is rated by analogy (38 C.F.R. § 4.20) to complete or partial paralysis of the sciatic nerve. See 38 C.F.R. § 4.124, Diagnostic Code 8520. That code provides that mild incomplete paralysis is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; moderately severe incomplete paralysis is rated 40 percent disabling; and severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Words such as "moderate" and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. Turning to the merits of the claim, the Veteran's service treatment records document her reports of neurological symptomatology affecting her lower extremities. A diagnostic letter received in April 2003 shows that the Veteran had been treated for lumbosacral radiculopathy. A July 2003 service treatment record includes the Veteran's report of having lower back pain and pain in her legs radiating down to her left leg to her knee. The associated physical examination revealed negative single leg raises, bilaterally; the assessment was lower back pain with left leg radiculopathy. She continued to report radiating pain down her left leg on a July 2003 report of medical examination; the associated July 2003 report of medical examination shows that the neurological examination and clinical examination of the lower extremities were both normal. In August 2003, she was assessed has having low back pain with questionable radicular signs and symptoms. A subsequent August 2003 service treatment record includes the Veteran's report of left low back pain with lower extremity numbness in the toes. On the clinical examination, single leg raises were positive for low back pain. The impression of low back pain on the left with no objective radicular findings. The Veteran's VA treatment records show that she underwent treatment for her low back symptomatology. She reported having low back pain with radiation to the left lower extremity in November 2003; the clinical examination revealed that her neurological functioning was grossly intact and she was diagnosed with intermittent low back pain with questionable radiculopathy. A December 2003 treatment record documents the Veteran's report of low back pain with radiation to the left leg, and tingling and numbness in the left foot. The associated clinical examination was negative for any neurological deficits. An April 2004 treatment record includes the Veteran's report of low back pain that occasionally radiated down to her legs and feet, along with mild numbness in her toes. Following a clinical assessment, she was diagnosed with generalized pain and questionable radiculopathy. The Veteran underwent a clinical assessment in May 2004, following complaints of low back pain with radiation to the left leg; the examination revealed no neurological deficits. She denied having experiencing radiating back pain in November 2004, at which time a clinical examination revealed negative straight leg raises. An April 2005 treatment record documents her report of low back pain, which intermittently radiated to her left lower extremity. She was noted to have a questionable history of radiculopathy. The physical examination revealed positive straight leg raises on the left. She continued to report low back pain with radiation to the left leg in January 2005. In February 2004, the Veteran underwent a VA examination to assessment her service-connected low back disability, during which she reported experiencing low back pain with radiation to the bilateral lower extremities. She also reported experiencing occasional numbness in her feet. The associated neurological examination was negative for any deficiencies. The Veteran was diagnosed with mechanical low back pain syndrome. The Veteran underwent a VA spine examination in July 2005, at which time she reported having low back pain with radiation to the left lower extremity. The neurological examination revealed that sensory function, motor function, and reflexes were within normal limits. The Lasegue's sign was negative. Following the examination, the diagnosis, in part, was degenerative joint disease of the lumbosacral spine. In support of her claim, the Veteran submitted letters dated in March 2008 and November 2008 from her VA treating physician, D.L., M.D. In both letters, Dr. D.L. stated that the Veteran had been treated for low back pain with sciatica since March 2003. She reported that a March 2008 physical examination of the Veteran revealed paravertebral back spasms and straight leg raises positive on the left. The Veteran was noted to treat her symptoms with prescription medications. In August 2010, the Veteran underwent a VA neurological examination, at which time the claims file was reviewed. She reported experiencing low back pain with radiation to the left lower extremity since an in-service injury to her low back in March 2003. The Veteran reported experiencing left lower extremity weakness, numbness, and cramps. According to the Veteran, she was told that she had a "pinched nerve" that resulted in her left leg pain. The physical examination revealed negative straight leg raises, and Patrick's test. Tenderness was noted on the left side of the back, without evidence of spasms or atrophy. Deep tendon reflexes were +2 for the bilateral lower extremities. Following the clinical examination, the diagnosis was left lumbosacral radiculopathy secondary to lumbar back disability, secondary to injury in service. Analysis The Board finds that the Veteran is entitled to a separate initial 10 percent rating for his left leg radiculopathy. Here, the Veteran has consistently complained of radiation of pain down her left leg, along with cramping and intermittent numbness and tingling in her left foot. In this regard, the Board finds the Veteran competent to describe her left lower extremity symptomatology. See Layno v. Brown, 6 Vet. app. 465, 469-470 (1994) (finding lay testimony competent when it concerns features or symptoms of injury or illness). The Board finds the Veteran's testimony as to her left lower extremity symptomatology to be credible, as there is no conflicting evidence of record. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Moreover, the medical evidence of record shows objective evidence of neurological impairments affecting the left lower extremity post-separation as early as April 2005. In this regard, the Veteran's treating VA physician, Dr. D.L. reported in letters dated in March 2008 and November 2008 that the Veteran was treated for sciatica associated with her low back disability since 2003; the physician further stated that a March 2008 clinical examination was significant for positive straight leg raises on the left, which the Board note is indicative of possible neurological impairments. While the August 2010 VA examination was negative for objective evidence of any neurological impairment, the physician diagnosed the Veteran with left lumbosacral radiculopathy secondary to her low back disability. When viewed in its entirety, and when all doubt is resolved in the Veteran's favor, the evidence of record indicates that the Veteran experiences, at least intermittently, neurological symptomatology affecting her left lower extremity that is distinct from but related to her low back disability. The Board finds that the Veteran's reported left lower extremity symptomatology and the objective medical evidence are more consistent with mild incomplete paralysis of the sciatic nerve and that the Veteran is entitled to a separate initial rating of 10 percent under Diagnostic Code 8520. The Board further finds that the Veteran's left lower extremity radiculopathy has not met the criteria for a rating in excess of 10 percent at any time since the grant of service connection. In this regard, although the Veteran has reported experiencing left leg weakness, there is no objective evidence of any sensory or motor deficits affecting her left lower extremity. Throughout the pendency of the appeal, the Veteran has essentially reported that her left leg symptoms are of a varying nature and severity; however, her reported symptomatology does not more closely approximate a moderate neurological disability. Given this, the evidence of record does not show that the Veteran's symptoms are of such a severity to constitute moderate incomplete paralysis under Diagnostic Code 8520. Consequently, the Board finds that the Veteran's left lower extremity radiculopathy is more accurately described as mild in nature than described as moderate in nature. As such, a disability rating in excess of the 10 percent rating assigned herein is not warranted. The Board has considered the Veteran's statements as to the nature and severity of her left lower extremity neurological symptomatology. The Veteran is certainly competent to report that her symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must only consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). To the extent that the Veteran argues or suggests that the clinical data supports an increased evaluation or that the rating criteria should not be employed, she is not competent to make such an assertion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (holding that a witness must be competent in order for his statements or testimony to be probative as to the facts under consideration). Finally, the Board has considered whether the Veteran's claim warrant referral to the Chief Benefits Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321. In Thun v. Peake, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. As has been explained fully herein, the Board finds that the separate disability rating assigned herein for the Veteran's left lower extremity neurological impairments contemplates the level of impairment reported by the Veteran, and there is no aspect of her disability that is not contemplated by the schedular criteria. Indeed, while higher ratings are available for the Veteran's disability, her symptomatology simply does not meet the criteria for a higher rating during the period currently on appeal. For these reasons, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321 is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). In this case the Veteran has been shown to have at most mild left lower extremity radiculopathy since the grant of service connection for her low back disability. Accordingly, from October 2, 2003, a separate initial rating of 10 percent, but no higher, is granted for left lower extremity neurological impairments. See Fenderson, 12 Vet. App. 119. ORDER A 50 percent disability rating for PTSD is granted, subject to the laws and regulations governing monetary awards. A separate 10 percent disability rating is warranted for neurological impairments of the left lower extremity associated with the service-connected low back disability, subject to the laws and regulations governing monetary awards. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs