Citation Nr: 1311182 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 07-22 928 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an evaluation in excess of 10 percent for herniated nucleus pulposus (HNP) with lumbosacral strain. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Becker, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1974 to October 1976. This matter comes before the Board of Veterans' Appeals (Board) from a January 2006 rating decision of the VA Regional Office (RO) in Nashville, Tennessee. A temporary 100 percent evaluation was assigned therein effective July 21, 2005, for the Veteran's HNP with lumbosacral strain based on surgical treatment necessitating convalescence. The previously established 10 percent evaluation was reassigned effective October 1, 2005. The Veteran appealed. In November 2010, the Board remanded this matter for additional development. Such development fully or at least substantially was completed, as set forth in more detail below. Adjudication accordingly. See Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with); aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The following determination is made based on review of the Veteran's claims file in addition to her Virtual VA "eFolder." FINDING OF FACT The Veteran's HNP with lumbosacral strain does not manifest forward flexion greater than 30 degrees but not greater than 60 degrees, combined range of motion not greater than 120 degrees, muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, or incapacitating episodes. (CONTINUED ON NEXT PAGE) CONCLUSION OF LAW None of the criterion for an evaluation in excess of 10 percent for HNP with lumbosacral strain has been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, 4.71a, Diagnostic Codes 5003, 5237, 5243 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Before addressing the merits, the Board preliminarily notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. VA must notify the claimant and her representative, if any, of any medical or lay (non-medical) evidence not of record that is necessary to substantiate the claim, that VA will seek to provide; and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). With respect to higher evaluation claims, generic rather than specific notification of the evidence needed to substantiate the claim must be provided. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (overturning Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008)). This includes evidence demonstrating a worsening or increase in severity of the service-connected disability at issue and the effect that worsening has on employment. Id. Notification on how disability evaluations and effective dates are assigned also must be provided. Id.; Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided prior to the initial decision by the agency of original jurisdiction (AOJ). However, there is no error in failing to provide prior notice when it was not required at the time of the initial AOJ decision. Notice followed by subsequent adjudication instead must be provided. Pelegrini, 18 Vet. App. at 112. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (overturning the Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007)); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been satisfied. Via letter dated in October 2005, the Veteran was informed of the criteria for establishing a higher evaluation, the evidence required in this regard, and her and VA's respective duties for obtaining evidence. This was prior to the aforementioned January 2006 rating decision by the RO, which also is the AOJ here, initially adjudicating her claim. The Veteran was informed via letters dated in March 2007 and December 2011 as well as in a December 2011 supplemental statement of the case (SSOC) of how VA determines disability ratings, which was noted to include consideration of the impact on employment, and effective dates. This was subsequent to the January 2006 rating decision, as the requirement to provide such notification first arose later in 2006 (Dingess was decided in March 2006). Subsequent adjudication occurred via a March 2007 statement of the case and the December 2011 SSOC. Whether or not they are in Federal custody, VA is required to assist the claimant in the procurement of pertinent records. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. §§ 3.159(c)(1-3). VA also is required to assist by providing a medical examination and/or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. §§ 3.159(c)(4). The Veteran's service treatment records, VA treatment records, and private treatment records from several facilities and/or physicians have been obtained through VA's efforts, the Veteran submitting them on her own behalf, or both. Of note is that some of the VA and private treatment records were obtained as a result of the Board's November 2010 remand. A VA medical examination was conducted in November 2005. The examiner reviewed the Veteran's medical records but not her claims file, interviewed her, and performed a physical assessment. That the claims file was not reviewed does not render the examination inadequate, as the examiner otherwise was familiar with the Veteran's history to include through her interview. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97 (2008). Yet the Board deemed the examination to be of questionable adequacy, given the Veteran's statements in that regard as well as its considerable age, in the November 2010 remand. Another VA medical examination therefore was directed. This examination was conducted in December 2010. The examiner reviewed the Veteran's claims file and medical records, interviewed her, and undertook a physical assessment. No allegation of inadequacy has been made. Considering the VA medical examinations collectively, all questions necessary to render the determination made herein have been answered. They therefore are adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Significantly, neither the Veteran nor her representative has identified any further development that has not been completed. The record also does not indicate any such development. The duty to assist thus has been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183. The duty to notify and the duty to assist both having been met, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Higher Evaluation The Veteran seeks a higher evaluation for her HNP with lumbosacral strain. She contends that this disability is more severe than contemplated by a 10 percent evaluation. A. Schedular Disability evaluations are based upon VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. Separate Diagnostic Codes identify various disabilities and the criteria for a specific percentage evaluation to be assigned for that disability. The evaluations represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C.A. § 1155. An evaluation is assigned by comparing the extent to which a Veteran's service-connected disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by symptomatology, with the criteria for the evaluations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Examination reports must be interpreted, and if necessary reconciled, into a consistent picture so that the evaluation may accurately compensate the elements of disability present. 38 C.F.R. § 4.2. If two evaluations are potentially applicable, the higher will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran therefore prevails when the evidence supports a higher evaluation or is in relative equipoise, but does not prevail when the evidence is against a higher evaluation. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where entitlement to compensation has already been established and an increase in rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Consideration nevertheless must be given to whether one or more staged evaluations is warranted. In staged evaluations, two or evaluations are assigned because a disability meets the criteria for one evaluation during one period on appeal but meets the criteria for another evaluation or evaluations during another or other periods on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss in the form of limitation of motion may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion, or weakness. 38 C.F.R. §§ 4.40, 4.59. It also may be due to excess fatigability or incoordination. 38 C.F.R. § 4.45. A higher evaluation for functional loss, to include during flare ups, due to those factors accordingly may be assigned under Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). 38 C.F.R. § 4.71a, Diagnostic Code 5003, addresses degenerative arthritis. It provides that this condition must be established by X-ray evidence. Evaluations for it are to be made on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. If evaluation on this basis results in a noncompensable evaluation, a 10 percent evaluation is assigned for each major joint or group of minor joints affected by limitation of motion. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of any limitation of motion, involvement of two or more major joints or two or more minor joint groups warrants a 10 percent evaluation. The same with occasional incapacitating exacerbations warrants a 20 percent evaluation. Diagnostic Code 5237 addresses lumbosacral strain. This disability is evaluated pursuant to the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). The General Rating Formula provides that disability evaluations are to be made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching. A 10 percent evaluation is merited when (1) forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, (2) the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, (3) muscle spasm, guarding, or localized tenderness is present but does not result in abnormal gait or abnormal spinal contour, or (4) there is a vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation requires (1) forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, (2) the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or (3) muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is assigned when (1) forward flexion of the thoracolumbar spine is limited to 30 degrees or less or (2) there is favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine results in a 50 percent evaluation. The maximum 100 percent evaluation is reserved for unfavorable ankylosis of the entire spine. The normal range of motion for the thoracolumbar spine is from zero degrees to 90 degrees forward flexion, zero degrees to 30 degrees extension, zero degrees to 30 degrees left and right lateral flexion, and zero degrees to 30 degrees left and right lateral rotation. General Rating Formula, Note (2); 38 C.F.R. § 4.71a, Plate V. Normal combined range of motion in the thoracolumbar spine is 240 degrees. Id. Each range of motion measurement is rounded to the nearest five degrees. Id., Note (4). Ankylosis is immobility and consolidation of a joint. Dorland's Illustrated Medical Dictionary 94 (31st ed. 2007); Lewis v. Derwinski, 3 Vet. App. 259 (1992); Nix v. Brown, 4 Vet. App. 462 (1993); Shipwash v. Brown, 8 Vet. App. 218 (1995). In other words, it is stiffening or fixation of a joint. Dinsay v. Brown, 9 Vet. App. 79 (1996). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. General Rating Formula, Note (5). Unfavorable ankylosis is where the entire thoracolumbar spine or the entire spine is fixed in flexion or extension which 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. Id. The General Rating Formula provides for the assignment of separate evaluations under appropriate Diagnostic Codes for any objective neurologic abnormalities associated with a disease or injury of the spine. General Rating Formula, Note (1). This includes, but is not limited to, bowel or bladder impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5243, has been used to evaluate the Veteran's HNP with lumbosacral strain. It addresses intervertebral disc syndrome (IVDS). Pursuant to this Code, IVDS is evaluated under either the General Rating Formula outlined above or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), whichever method results in the higher evaluation. Incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months is needed for a 10 percent evaluation. A 20 percent evaluation is for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. Incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months results in award of a 40 percent evaluation. The maximum evaluation of 60 percent is awarded for incapacitating episodes having a total duration of at least six weeks during the past 12 months. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Formula for Rating IVDS, Note (1). Each spinal segment manifesting clearly distinct effects of IVDS is to be evaluated separately. Id., Note (2). The probative value of the evidence must be assessed. 38 C.F.R. § 4.6. In other words, the Board must account for evidence which it finds to be persuasive or unpersuasive and provide reasons for rejecting any evidence favorable to the Veteran. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Only the most relevant evidence need be discussed, however, even though all the evidence must be and thus has been reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Since July 2004, VA treatment records have reflected a diagnosis of chronic low back pain. Private treatment records dated in August and December 2004 document the presence of pain, tenderness, and spasms in her back. Magnetic resonance imaging (MRI) performed in May 2005 showed disc degeneration at L5-S1, among other things. A left L4-L5 laminar microdiskectomy was performed privately in July 2005. It was noted in a November 2005 private treatment record that the Veteran was doing well following this procedure. The report of the November 2005 VA medical examination reveals the following. The Veteran complained of occasional mild pain, mild stiffness, and mild decreased motion. She further complained of moderate flare-ups lasting one day every three to four months which cause mild limitation of motion or functional impairment over and above normal as well as two days of incapacitating episodes during recovery from her surgery. She denied weakness, fatigue, and spasms as well as urinary incontinence, urinary frequency, urinary urgency, urinary retention, fecal incontinence, and obstipation. The Veteran's posture and gait were normal. She had no abnormal spinal curvature and no ankylosis. No tenderness, pain with motion, weakness, atrophy, spasm, or guarding was detected. It was determined that there was no localized tenderness, guarding, or spasm severe enough to be responsible for abnormal gait or spinal contour. The Veteran's thoracolumbar spine range of motion initially was from zero to 90 degrees flexion and from zero to 30 degrees extension, right and left lateral flexion, and right and left lateral rotation. There was no change due to pain, fatigue, weakness, or lack of endurance with repetition. July 2004 X-rays were noted to have shown degenerative disc disease (DDD) particularly at L4-L5 and L5-S1. Much of the aforementioned examination report subsequently was contested by the Veteran. She indicated in her January 2007 notice of disagreement and in statements dated in January and July 2007 that she has daily pain ranging from mild to excessive, daily fatigue/lack of endurance, weakness, near constant spasms, gait and posture changes, and limitation of motion. Specifically, she noted her pain is severe on average of two days per month. She stated fatigue and lack of endurance inhibit her functioning. The Veteran argued weakness is obvious as she has had two surgeries (one was in 2001). She noted the examiner commented on how badly her back was spasming. She maintained she basically walks flat-footed due to pain on flexion and that, with severe spasms, her back is pulled to one side. This was described as extremely uncomfortable. She admitted she can bend at the waist and touch her right foot, but indicated she could not bend and touch her left foot. Finally, the Veteran argued that the necessity of two surgeries conveys worsening and that her condition cannot be that moderate given the impact it has on her. At the December 2010 VA medical examination, the Veteran reported constant daily mild to moderate pain, weakness, fatigue, stiffness, spasm, and decreased motion. She also complained of moderate to severe flare-ups lasting one day to seven days four to five times a year which cause limitation of motion due to pain. She denied urinary incontinence, urinary frequency, urinary urgency, urinary retention requiring catheterization, fecal incontinence, and obstipation. It was noted that the Veteran did not have incapacitating episodes. Her posture and gait were normal. She had no abnormal spinal curvature and no thoracolumbar spine ankylosis. No tenderness, weakness, atrophy, spasm, or guarding was detected. It was determined that there was no localized tenderness, guarding, or spasm severe enough to be responsible for abnormal gait or spinal contour. The Veteran's thoracolumbar spine range of motion initially was from zero to 70 degrees flexion, zero to 20 degrees extension, zero to 28 degrees right lateral flexion, zero to 22 degrees left lateral flexion, zero to 20 degrees right lateral rotation, and zero to 30 degrees left lateral rotation with pain. There was pain with repetition, but no change in range of motion. Three points are notable at the outset. First, the period prior to October 1, 2005, is not considered herein because it is not on appeal. The 100 percent temporary evaluation assigned for this period indeed is the maximum that can be awarded. Second, the Veteran is a lay person because there is no indication that she has any medical background. She is competent to report her symptoms because she experiences them. Layno v. Brown, 6. Vet. App. 465 (1994). Competent lay evidence may be discounted "in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). Factors for consideration therefore include a showing of interest, self-interest, bias, inconsistent statements, inconsistency with other evidence of record, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. See Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). The Veteran's credibility is addressed below when necessary. Third, discussed above was that the November 2005 VA medical examination is of only questionable adequacy. This is true particularly with respect to what the Veteran purportedly reported and denied at the examination. It accordingly has less probative value than the December 2010 VA medical examination. Nevertheless, it retains some probative value and thus is not rejected outright. This is true particularly with respect to the findings made at the examination. The Board finds, based on the above, that an evaluation in excess of 10 percent for HNP with lumbosacral strain is not warranted. One pertinent Diagnostic Code does not apply. The other Diagnostic Codes do apply, but none of the criterion set forth in them for even the next higher evaluation of 20 percent is met. X-rays and MRI show degeneration. However, Diagnostic Code 5003 applies only when there is noncompensable limitation of motion or no limitation of motion. There is compensable limitation of motion here. Forward flexion indeed was greater than 60 degrees but not greater than 85 degrees at the December 2010 VA medical examination. With respect to Diagnostic Code 5237 and thus the General Rating Formula, thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees is not found. The Veteran had 90 degrees of forward flexion at the November 2005 VA medical examination. She disputes this finding, but it nevertheless stands as accurate or approximately accurate. Even if presumed to be credible as well as competent, that she cannot touch her left foot when she bends at the waist does not necessarily suggest forward flexion under 60 degrees. The opposite, or forward flexion greater than 60 degrees, indeed is suggested since she can bend at the waist and touch her right foot. The Veteran further had 70 degrees of forward flexion at the December 2010 VA medical examination. Combined range of motion in the thoracolumbar spine not greater than 120 degrees also is not found. The Veteran had a combined range of motion of 240 degrees at the November 2005 VA medical examination. She had a combined range of motion of 190 degrees, with and without rounding, at the December 2010 VA medical examination. It is acknowledged that some of the Veteran's thoracolumbar forward flexion and combined range of motion was with pain. Acknowledgement also is given to her competent reports of weakness and fatigue/lack of endurance. These reports are credible because there is no significant reason to doubt them. They indeed are facially plausible and consistent with one another, and the only inconsistency with the other evidence is the Veteran's purported denials at the November 2005 VA medical examination. Yet motion that is painful does not constitute limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain rather must actually prevent motion. The same principle applies to motion affected by weakness and fatigue/lack of endurance. Here, the pain, weakness, and fatigue/lack of endurance the Veteran experiences has not resulted in thoracolumbar forward flexion greater than 30 degrees but not greater than 60 degrees or combined range of motion not greater than 120 degrees. She indeed had over 60 degrees of forward flexion and over 120 degrees of combined motion both initially and with repetitive motion at both VA medical examinations. Further acknowledgement is given to the Veteran's competent reports of flare ups of her aforementioned symptoms, particularly pain. These reports are credible because, once again, there is no significant reason for doubt. They are facially plausible, consistent with one another, and not inconsistent with the other evidence. However, there is no indication that thoracolumbar forward flexion is greater than 30 degrees but not greater than 60 degrees or combined range of motion is not greater than 120 degrees. The amount of additional limitation of motion beyond normal was not set forth at the December 2010 VA medical examination. Such additional limitation of motion purportedly was described by the Veteran as mild at the November 2005 VA medical examination. Even assuming the Veteran's thoracolumbar forward flexion is greater than 30 degrees but not greater than 60 degrees and/or her thoracolumbar combined range of motion is not greater than 120 degrees during flare ups, she rarely is experiencing one. The frequency competently and credibly reported by her at the December 2010 VA medical examination had a high of 28 days per year. The frequency competently and credibly reported by her at the November 2005 VA medical examination had a high of four days per year. In other words, she is far more often not having a flare up than having a flare up. It follows that the thoracolumbar forward flexion and combined range of motion found at the aforementioned VA medical examinations is accurate for a majority of the time. Lastly, muscle spasm or guarding severe enough to have resulted in an abnormal gait or abnormal spinal contour is not found. The Veteran had spasms prior to her surgery. Neither guarding nor spasms were manifested by her at either VA medical examination following this surgery. She disputes this finding of no spasms from the November 2005 VA medical examination, noting that the examiner commented on the severity of her back spasms. She additionally, with the exception of her purported denial at the aforementioned examination, has reported spasms. Even if the Veteran is presumed to be credible as well as competent such that spasms are found, neither her spinal contour nor her gait is abnormal. No abnormal spinal curvature was found at either VA medical examination. The Veteran has not contended specifically that such curvature exists. Her competent report that her back is pulled to one side is indicative only of a posture change. It further is not credible, given that it is inconsistent with both VA medical examinations finding her posture to be normal. Regarding abnormal gait, the Veteran's competent report of walking basically flat-footed also is not credible due to inconsistency. Her gait was normal at both VA medical examinations. It finally was determined at both examinations that there was no guarding or spasm severe enough to be responsible for abnormal gait or spinal contour. The lay evidence from the Veteran, in sum, has been considered but is outweighed by the medical evidence. All that remains for consideration under the General Rating Formula is whether or not there is any objective neurologic abnormality associated with HNP with lumbosacral strain. A separate evaluation is not warranted for associated bowel impairment or for bladder impairment. No objective findings of bowel or bladder problems have been made, much less made and then attributed to the Veteran's HNP with lumbosacral strain. This is not surprising, as she denied all such problems at both VA medical examinations. Service connection was granted and initial evaluations assigned for associated radiculopathy of the right lower extremity and of the left lower extremity in a December 2011 rating decision. The Veteran did not appeal either determination. Thus, no consideration of her legs is necessary. There finally and predictably is no objective indication of any other associated neurologic abnormality since none have been reported by her. The December 2011 rating decision also granted service connection and assigned an initial evaluation for a left L4-L5 laminar microdiskectomy scar. Unlike above, the scar is not an objective neurologic abnormality associated with her HNP with lumbosacral strain. Yet no consideration of it is necessary. This is because the determination regarding it, like above, was not appealed by the Veteran. Turning to IVDS, the Veteran has DDD which is similar to IVDS in that both involve disc problems. The Formula for Rating IVDS therefore applies. Yet there is no indication of incapacitating episodes of any duration. Incapacitating episodes during surgery recovery cannot be considered here, as discussed above. It otherwise was noted that the Veteran did not have incapacitating episodes. She indeed has not required treatment by a physician for a period of acute signs and symptoms. It appears that she receives little if any treatment, whether on an emergency or urgent basis or otherwise, for her HNP with lumbosacral strain. At no point has bed rest been prescribed by a physician. Indeed, no reference to bed rest has been made. Use of the Formula for Rating IVDS, as such, would result in a noncompensable evaluation. The 10 percent evaluations assigned pursuant to the General Rating Formula accordingly stand as the higher evaluation. Consideration has been given to reasonable doubt in determining that the 10 percent evaluation for HNP with lumbosacral strain should be continued. However, it does not apply because the evidence is against a higher evaluation. Consideration also has been given to staged evaluations. It follows that none are warranted because the aforementioned determination covers the entire period under appeal. B. Extraschedular As an alternative to assigning an evaluation schedularly, an evaluation may be assigned on an extraschedular basis. 38 C.F.R. § 3.321(b). Steps to be taken regarding extraschedular evaluations were set forth in Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the evidence presents such an exceptional disability picture that the applicable schedular evaluation criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made. If these criteria are inadequate, it must be determined whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for consideration of an extraschedular evaluation. Neither the Veteran nor her representative has argued for an extraschedular evaluation. There is no indication that HNP with lumbosacral strain could not be contemplated adequately by the applicable schedular evaluation criteria discussed above. Its predominant symptoms, whether established (found or competently and credibly reported) or simply reported (not found and competently but not credibly reported), are pain/tenderness, stiffness, weakness, fatigue/lack of endurance, spasms, limitation of motion, and gait and posture abnormalities. They specifically are accounted for by the criteria and associated statutes, regulations, and caselaw. Evaluation was based on these sources. Higher evaluations exist pursuant to them. As explained above, however, the evaluation of 10 percent accurately describes the severity of the disability. In other words, the effect it has on the Veteran is encompassed by this evaluation. This includes her treatment with medication, massage, a brace, and a TENS unit as well as interrupted sleep, problems with lifting and carrying, intermittent problems with bathing and dressing, and some need for assistance with household chores and house and yard maintenance. Given that the applicable schedular evaluation criteria are adequate, the Board does not find an exceptional HNP with lumbosacral strain disability picture. Discussion of whether there are related factors such as marked interference with employment or frequent periods of hospitalization accordingly is unnecessary. Of note, however, is that the Veteran competently and credibly reporting missing a few weeks of work and having to take one position over another is insufficient to constitute marked interference with employment. There is no indication of any periods of hospitalization. Referral for consideration of the assignment of an evaluation on an extraschedular basis thus is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). III. Total Disability Evaluation Based on Individual Unemployability Of final note is that "a request for entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU), whether expressly raised by a [V]eteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities ... as part of a claim for increased compensation." Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case, the Veteran's HNP with lumbosacral strain is not so severe that it has rendered her unemployable. She indeed competently and credibly has reported being employed full-time. Consideration of TDIU as a component of this matter thus is not warranted. ORDER An evaluation in excess of 10 percent for HNP with lumbosacral strain is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs