Citation Nr: 1300914 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 08-09 401 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disorder (other than the service-connected shrapnel fragment wound and related scar). 2. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from July 1963 to June 1966. The Veteran is in receipt of a Purple Heart. The Veteran's claim comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision of the Department of Veterans Affairs' (VA) Regional Office (RO) in Waco, Texas and a March 2012 Board remand. In July 2010, the Veteran testified during a hearing before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is also of record. The Board has considered documentation included in the Virtual VA system in reaching the determination below. At present, the system contains VA treatment records that are not physically in the file, but that were considered by the RO in the last supplemental statement of the case. In this vein, the Board notes that in its March 2012 decision/remand, the issue of entitlement to service connection for diabetes mellitus was referred to the AOJ for development. A June 2011 rating decision contained in the Veteran's Virtual VA file only reflects that service connection was awarded for this disability. Accordingly, further referral of the issue is not necessary. FINDINGS OF FACT 1. The Veteran's low back disability (other than his service-connected shrapnel fragment wound and related scar) is not shown to be causally or etiologically related to service, and is not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from service. 2. Since his June 28, 2007 date of claim, the Veteran's PTSD has not been manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability (other than his service-connected shrapnel fragment wound and related scar) have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & 2012); 38 C.F.R. §§3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for an initial rating in excess of 10 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable 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). The Board finds that the content requirements of a duty to assist notice have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in July 2007 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claims, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The letter additionally provided the Veteran with information concerning the evaluation and effective date that could be assigned should his claims be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. His service treatment records and post service treatment records have been obtained. He has had two hearings, one before the RO and one before the Board. He has been afforded VA examinations. The most recent VA examinations are adequate as the spine examination provided an etiological opinion based upon a review of the relevant facts in the claims file, an examination of the Veteran, and included a supporting rationale. Likewise, the psychiatric examination is adequate as it addresses the Veteran's psychiatric symptoms as relevant to the diagnostic criteria. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board does not have notice of any additional relevant evidence which is available but has not been obtained. The Board is further satisfied that the RO has substantially complied with its March 2012 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board, the AOJ secured additional VA treatment records, afforded the Veteran the opportunity to submit any additional evidence pertinent to the claims, and provided VA examinations for his low back disability and PTSD. See 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Service Connection Claim Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as malignant tumors, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.303(b), an alternative method of establishing service connection is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a disorder when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.") In this case, an April 2012 VA examination report shows that the Veteran has been diagnosed with degenerative disc disease of the lumbar spine. As for the in-service incurrence of the condition, the Veteran contends that in November 1964, he was shoveling ice and snow off the top of a military ambulance and fell approximately eight feet to the ground, injuring his low back and breaking his clavicle. Service treatment records show that the Veteran entered service with no abnormalities of the spine. The November 1964 accident is confirmed in the records, although the records are silent for complaints involving the low back. Rather, the records exclusively pertain to the Veteran's fractured clavicle. A March 1966 record shows a shrapnel wound to the left posterior thorax, which was debrided and sutured. The Veteran's separation examination notes the presence of a scar on the back and occasional discomfort due to the wound. In April 2012, a VA examination was conducted. The examiner reviewed the claims file as well as the Veteran's contentions, and noted the Veteran's November 1964 accident in which he fell from the top of the ambulance, as well as the subsequent shrapnel injury. He concluded that the Veteran's current low back condition is not related to military service. In explanation, he noted there is no evidence of any complaint or treatment for a low back condition in the service treatment records. The examiner noted that the records surrounding the 1964 accident are silent for any complaints other than of the clavicle, and the separation examination was negative for any spine abnormalities. The examiner further noted that there is no interim data proximate to discharge. Additionally, he found that the 1966 shrapnel injury did not penetrate to the depth of the spine or spinal contents to cause the current problem. For all of these reasons, the examiner also determined that the disability is degenerative in nature and is more likely related to aging and attrition. The Board finds that the evidence of record does not support a finding of service connection for a low back disorder. There is a current disability and an in-service event. Although there is an inservice event, the Board finds that the Veteran's lay statements regarding a low back injury at that time competent, but not credible. The Veteran is competent to report such symptoms after a fall, but is not credible in this instance, based on eyewitness testimony provided at the Board hearing, and the lack of complaints in the STRs at the time of the accident, despite there being other complaints made at that time. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006) (noting that the Board must determine whether lay evidence is credible due to possible bias, conflicting statements, and the lack of contemporaneous medical evidence, although that alone may not bar a claim for service connection). See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (noting that the absence of actual evidence is not substantive evidence, but may be evidence against the existence of a fact if it would ordinarily be recorded) (citations omitted). This is despite the Veteran's combat status as this incident was unrelated to any combat service and he sought and received treatment thereafter. See 38 U.S.C.A. § 1154 (West 2002) (providing that for combat veterans, VA shall accept lay statements as sufficient evidence of in-service incurrence if consistent with the circumstances, conditions, or hardships of such service). Additionally, the other competent, credible, and probative evidence of record is not contrary to the April 2012 examiner's opinion. In reaching this decision, the Board notes that the Veteran, on his own behalf, has contended that his current back disability is related to military service. However, the Veteran is not competent as a layperson, to render an opinion concerning medical causation here, where the "where the question involved does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge", to include knowledge of the processes of developing degenerative joint disease, as opposed to providing evidence of ringing in the hears or the presence of varicose veins. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); see also Barr v. Nicholson, 21 Vet. App. 303, 310 (2007) (holding that varicose veins are capable of lay observation and thus lay testimony may serve to establish a diagnosis); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (lay testimony may establish the presence of tinnitus because ringing in the ears is capable of lay observation). In this regard, the Veteran, as a layperson, lacks the competency to opine on the etiological cause of his degenerative disc disease of the lumbar spine. Thus, there is no in-service event to support a claim of service connection, either based on a nexus to service or on continuity of symptoms. See 38 C.F.R. § 3.303(a), (b). To the extent the Veteran reports a continuity of symptomatology since discharge, the Board finds he is competent to report this symptomatology. His testimony, however, is outweighed by the negative nexus opinion and that the earliest post-service documentation of a low back disability is dated from 2007, 40 years post service. See Maxon v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (holding that evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim.). Finally, certain diseases, chronic in nature, may be presumed to have been incurred in service, if the evidence shows that the disease became manifest to a degree of 10 percent or more within one year from separation from active service, even though there is no evidence of the disease during service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). Arthritis has been identified as a chronic disease subject to presumptive service connection under 38 C.F.R. § 3.309(a). However, as there is no medical evidence documenting arthritis of the lumbar spine from within one year of the Veteran's discharge from active duty in June 1966, the Board finds that presumptive service connection is not warranted on this basis. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Claim Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The assignment of a particular diagnostic code is 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. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In the December 2007 rating decision on appeal, the RO awarded service connection for PTSD and assigned a 10 percent evaluation, effective from his June 28, 2007 date of claim. The Veteran expressed his timely disagreement with the rating assigned and the present appeal ensued. Given that the Veteran appealed the initial evaluation assigned, the severity of his disability is to be considered during the entire period from the initial assignment of the disability rating to the present. Fenderson v. West, 12 Vet. App. 119 (1999). The relevant time period for consideration in a claim for an increased initial disability rating is the period beginning on the date that the claim for service connection was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). Pursuant to the General Rating Formula for Mental Disorders, a 10 percent rating is assigned where there is evidence of 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 evaluation is assigned where there is evidence of occupational and social impairment with an 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, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned where there is evidence of 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; difficulty in establishing and maintaining effective work and social relationships. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran's disorder, and the effect of those symptoms on the claimant's social and industrial adaptability. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining the appropriateness of the evaluation assigned to the Veteran's disability, the Global Assessment of Functioning (GAF) scores assigned by medical providers throughout the course of this appeal will be discussed. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) at 44-47. A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Considering the Veteran's psychiatric symptomatology in light of the above, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's PTSD. On VA examination in November 2007, the Veteran was noted to have been married for thirty one years with two children. He described a good relationship with his wife, mother, siblings, and sons. He reported having some friends and being involved at church. He was retired from AT&T, where he worked for at least 18 years. For leisure, he reported that he enjoyed socializing, hunting, fishing, and watching football with friends. Subjectively, the Veteran reported sleep disturbances, and some depression and anxiety. On examination, the Veteran was articulate, verbal, and generally cooperative. Social skills were fair. Thought processes were logical, coherent, and relevant. Affect was flat. The Veteran was oriented, and reasoning and judgment were good. Fund of general information and verbal comprehension were average. The Veteran reported some mild problems with concentration and short-term memory, but he was able to function well. Long-term memory was intact. He denied any psychotic or manic symptoms. He reported some mild depressive symptoms including anhedonia, increased appetite, fatigue, feelings of worthlessness, and a sad mood. He reported, however, that these symptoms typically lasted from one day to three or four days before disappearing. He reported mild anger and irritability, and denied suicidal and homicidal ideation. Overall, the examiner characterized the Veteran has manifesting a fairly mild depressed mood and dissatisfaction with life, and being somewhat socially withdrawn. The examiner concluded that the Veteran's PTSD was "very mild" and in "partial remission." He was assigned a GAF score of 75, which contemplates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors, for example, difficulty concentrating after a family argument, or there is no more than slight impairment in social, occupational, or school functioning, such as temporarily falling behind in schoolwork. See DSM-IV at 46-47. In a February 2008 VA treatment record, the Veteran reported that in the past two weeks, he had not been bothered by having little interest or pleasure in doing things. Over the past two weeks, he had not been bothered by feeling down, depressed, or hopeless. His score on the PHQ-2 screen was zero, which is a negative screen for depression. His PTSD screening test was also negative. He reported experiencing nightmares and thinking about upsetting experiences from the past when he did not want to. He denied that such upsetting experiences from the past caused him to go out of his way to avoid situations reminding him of them. He further denied being constantly on guard, watchful, easily startled, numb, or detached from others, activities, or surroundings because of the upsetting experiences from the past. At his June 2008 hearing before the DRO, the Veteran reported having anxiety, a short temper, depression, detachment, suspiciousness, sleep problems, and short term memory problems, including forgetting names. He reported that when he worked, it was difficult working with other people. He denied that his symptoms ever resulted in disciplinary actions at work. He reported that he had never received treatment for his PTSD because he was unaware that treatment was available through VA. See Hearing Transcript, pp. 1-4. At his July 2010 Board hearing, the Veteran testified that he suffered from anxiety, depression, two panic attacks in the past year, suspiciousness in large groups, marital difficulties, and sleep problems. He provided similar testimony to that in June 2008 regarding his difficulties with PTSD in his former employment setting. He reported difficulties with memory, including names and complex directions. He reported having trouble socializing and having a difficult relationship with his older son. See Hearing Transcript, pp. 3-8. On VA examination in April 2012, the Veteran reported that he continues to live with his wife of thirty-six years, and that he enjoys fishing, hunting, shooting, spending time with his grandchildren and friends, and working in the yard. It was noted that the initial PTSD evaluation was conducted in November 2007, and that there had been no significant changes since then. The Veteran's current symptoms were identified as anxiety, chronic sleep impairment. The examiner did not check the boxes identifying the presence of symptoms such as depression, suspiciousness, panic attacks, or memory loss. The examiner checked a box indicating which statement best summarized the Veteran's level of occupational and social impairment caused by his mental disorders, which noted that the Veteran experiences 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 medication. The examiner assigned a GAF score of 75, which contemplates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors, for example, difficulty concentrating after a family argument, or there is no more than slight impairment in social, occupational, or school functioning, such as temporarily falling behind in schoolwork. See DSM-IV at 46-47. The Board finds that the evidence of record does not demonstrate entitlement to an evaluation in excess of 10 percent. First, the Veteran's GAF scores indicate that in 2007 and 2012, his PTSD was manifested by transient symptoms or expectable reactions to psychosocial stressors, or no more than slight impairment in social, occupational, or school functioning. See DSM-IV at 46-47. These scores tend to support the 10 percent, and not the 30 percent evaluation, as the 10 percent evaluation contemplates occupational and social impairment due to mild or transient symptoms and a 30 percent evaluation contemplates occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks. 38 C.F.R. § 4.130. Additionally, the 2012 VA examiner noted that the evidence did not show occupational and social impairment with an 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, directions, recent events). 38 C.F.R. § 4.130. The record shows evidence of some symptoms contemplated by the 30 percent rating. Specifically, the record shows competent and credible lay and other medical evidence of a depressed mood, anxiety, chronic sleep impairment, and mild memory loss. But the level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not the symptoms listed in the rating criteria, which are representative, not exclusive. See Mauerhan, 16 Vet. App. 436. Here, the examiners have consistently noted the impact on social and occupational functioning to be slight. These findings outweigh the Veteran's lay evidence in this regard. Accordingly, an increased evaluation is not warranted. The Board has considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). There are no exceptional or unusual factors with regard to the Veteran's PTSD. The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical.") Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, as they address various psychiatric symptoms and their effect on social and occupational functioning, and provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-schedular consideration is not warranted. Finally, the Board considered whether an inferred claim for a total disability rating based on individual unemployability has been raised Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that the Veteran is no longer employed. He has not, however, alleged that he is, or ever was, unemployable on account of his PTSD. To the contrary, the evidence shows the Veteran retired after thirty-three years of employment. As such, the Board finds that Rice is inapplicable in the present case. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a low back disorder (other than the service-connected shrapnel fragment wound and related scar) is denied. An initial increased disability rating in excess of 10 percent for PTSD is denied. ____________________________________________ K. MILLIKAN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs