Citation Nr: 1315417 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 09-39 832 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to a rating in excess of 10 percent for a cervical spine disability. 2. Entitlement to a rating in excess of 10 percent for a lumbar spine disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. The Veteran testified at a hearing at the RO in April 2010. A transcript of the hearing is associated with the claims folder. FINDINGS OF FACT 1. The Veteran's cervical spine disability has been manifested at worst by a combined range of motion of the cervical spine of 325 degrees with pain. 2. The Veteran's lumbar spine disability has been manifested by full range of motion without objective evidence of pain. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5237, 5242 (2012). 2. The criteria for a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5237, 5242 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002 & Supp. 2012)); see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a) (2012), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In Pelegrini v. Principi, 17 Vet. App. 412 (2004), the United States Court of Appeals for Veterans Claims (Court) held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this case, the Veteran was provided VCAA notice in a March 2007 letter, advising her of what information and evidence is needed to substantiate her claims for increased ratings, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter included information regarding how disability evaluations and effective dates are assigned and the type of evidence that impacts those determinations. The case was last adjudicated in November 2011. The Veteran has received all essential notice and has had a meaningful opportunity to participate in the development of her claims. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Board also finds that VA has complied with all assistance provisions of the VCAA. The evidence of record contains the Veteran's service treatment records, VA and private treatment records, VA examination reports and medical opinions, and lay statements and hearing testimony. The examination reports include the information necessary to rate the disabilities at issue. There is no indication of relevant, outstanding records that would support the Veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues being decided on appeal. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; assigning the higher rating where there is a question as to which of two evaluations apply and where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Hence, the following analysis in the case is undertaken with the possibility that staged ratings may be appropriate. It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range-of-motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Veteran's cervical spine and lumbar spine disabilities are each rated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5299-5237. VA regulations provide that conditions not listed in the rating schedule will be rated by analogy and coded with the first two numbers of the schedule provisions for the most closely related body part and "99." Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 5237 provides that disabilities manifested by lumbosacral or cervical strain are rated under the General Rating Formula for Diseases and Injuries of the Spine. (The Board notes that x-ray evidence has shown some indication of arthritis, which is also rated on the basis of the general rating formula in accordance with Diagnostic Code 5242. Likewise, the record reflects assessments of disc disease in the cervical spine at times. Disc disease disability is ratable under the general rating formula, like arthritis, but may in the alternative be rated under criteria for intervertebral disc syndrome found at Diagnostic Code 5243. These criteria require that there be incapacitating episodes having a total duration of a least 2 weeks during a 12-month period to warrant higher than a 10 percent rating. (An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. Note 1 following Diagnostic Code 5243.)) General Rating Formula for Diseases and Injuries of the Spine: (For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes): Rating With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire spine 100 Unfavorable ankylosis of the entire thoracolumbar spine 50 Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine 40 Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine 30 Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis 20 Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height 10 Note: (1) Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note: (2) (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note: (3) In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note: (4) Round each range of motion measurement to the nearest five degrees. Note: (5) For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note: (6) Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a (2012). 38 C.F.R. § 4.71a, PLATE V (2012). Private treatment records dated in February 2005 from Medical Associates Clinic reveal that the Veteran was evaluated for neck and back pain. The conclusion of a cervical spine MRI was some desiccation of the disc and mild disc space narrowing at L4-5 and L5-S1; the MRI of the lumbar spine was otherwise normal. The conclusion of a cervical spine MRI was bulging disc at C5-6 and further evaluation needed at C6-7 to determine whether there was a prominent bulging disc or a focal herniated disc. The Veteran's physician, P. Lynn, M.D., reviewed the MRI reports and indicated that the lumbar MRI showed some normal age-consistent desiccation but nothing unusual and nothing that would be the cause of significant pain. Dr. Lynn explained that she believed the neck pain was very likely muscular. Following a physical examination, Dr. Lynn concluded that the Veteran's primary problem was that she needed to exercise and she suspected that the Veteran had never started out at a low enough level to get strong enough to do the things she likes to do. Dr. Lynn emphasized that there was nothing going on with regard to the structure in the low back. In her December 2006 claim, the Veteran indicated that her low back disability had "only deteriorated a bit," but her neck pain had "increased dramatically." She reported daily pain of varying levels and indicated that she saw a chiropractor and massage therapist each once per month and that she visited the doctor every five to six months when her disability flares up, which often leads to physical therapy. She added that the amount and types of medication that she takes to tolerate pain had also increased. A December 2006 private treatment record from Medical Associates Clinic listed hydrocodone bitartrate and acetaminophen (Vicodin) and propoxyphene napsylate/acetaminophen (Darvocet-N) among current medications. During a March 2007 annual examination at Medical Associates Clinic, she stated that her back pain was stable. Past medical history included neck and back pain. The assessment included neck pain and back pain. During April 2007 private treatment with P. Lynn, M.D., from Medical Associates Clinic, the Veteran reported having burning discomfort in the upper back, neck area, as well as some history of low back pain, which had been on and off for several years. She stated that she had been taking stronger medications to try to control the pain. She also reported taking stronger medications at least once a week for increased headaches. She indicated that she worked in an administrative position at a computer, generally sitting at least seven or eight hours per day. On examination, cervical motion noted tolerance for forward bending with slight discomfort with extension, more pulling discomfort with left rotation than right, tightness bilaterally with side bending component, and no radicular symptoms. The diagnosis was bilateral neck pain and occipital pain. During follow-up treatment at Medical Associates Clinic in May 2007, the Veteran reported that her neck pain remained the same. She related a significant flare-up of her back pain without specific cause. She received therapeutic exercise treatment and electrical stimulation with heat. Four days later in May 2007, she reported that her neck pain decreased to a 1/10 level with 80 to 90 percent frequency. She rated her low back pain as a 3-4/10. The physician indicated that the Veteran's range of motion had increased, but she had a remaining trigger point in the right upper trapezius muscle. During another visit with Dr. Lynn in May 2007, she reported nonradicular back pain and chronic muscular neck pain. On examination there were tender trigger points in the trapezius on both sides and she received injections. Regarding her low back, she was advised to do exercises because her sacroiliac joints were not level. The assessment was low back pain, myalgia/myositis, and neck pain. The Veteran failed to report for a VA spine examination in July 2007 and the RO denied the claims for increased cervical and lumbar spine disability ratings. During treatment at Medical Associates Clinic in September 2007 for complaints of migraine headaches, the Veteran stated that approximately every three weeks she missed one to three days of work due to her headaches, which were getting worse. On examination, range of motion of the cervical and lumbar spine was reported as normal and she walked with a normal gait. In January 2008, she reported neck pain. Dr. Lynn noted that a 2005 MRI of the cervical spine was unremarkable other than for a disc herniation at C6-7 on the right. She noted that the Veteran was not really complaining of radicular pain; about a week earlier the Veteran fell and she reported increased weakness in the left arm. On examination there was no weakness to testing. She received injections in the upper trapezius bilaterally. During a July 2008 examination, she stated that her history of back and neck pain was stable. Private treatment records dated from December 2006 to December 2008 from Chiropractic First revealed that the Veteran complained of neck and stiffness with pain going down her arms, headaches, shoulder pain, and low back pain. She received treatments and at-home stretching exercises were recommended. She appeared for a VA spine examination in December 2008. When asked to describe her neck disability, the Veteran stated that most of the problem she had was in the right shoulder. She reported seeing Dr. P. Lynn one year ago with no follow-up scheduled; seeing her family physician, C. Nachtman, M.D., two years ago; and seeing a chiropractor and a massage therapist every four weeks. She reported that she took Motrin once per day, Darvocet once per month, Vicodin once or twice per month, and Flexeril once or twice per month with good results and no problems. She reported a monthly occipital to bifrontal headache lasting two days and being told they were "migraines." She also reported a nonradiating constant aching pain located in the base of the neck and shoulders made worse with "any activity" and better with rest and the above-noted medicines. She endorsed vague weakness, "a little bit" of stiffness, fatigability, and lack of endurance. She reported one to two periods of moderate flare-up of neck pain per week precipitated by a lot of filework and alleviated by rest and medicines. Regarding her back disability, she reported a nonradiating intermittent sharp lower lumbar pain made worse with the same factors as the neck and better with Motrin and Darvocet and supine or side position. She reported weakness with less than expected strength, stiffness, fatigability, and lack of endurance. She stated that the pain was progressively worse in frequency with the same severity, not as bad as the neck. She reported periods of moderate flare-up of low back pain precipitated by cleaning the house and alleviated by medications. Regarding the cervical and lumbar spine, she denied swelling, heat, redness, instability, giving way, locking, loss of motion, or deformity. She walked unaided with a steady gait with no history of falls and without a brace, assistive device, or orthesis. On physical examination, posture and gait were normal; there was no scoliosis, reversed lordosis, or abnormal kyphosis; there was no cervical or thoracolumbar spine ankylosis; and there was no spasm, atrophy, guarding, pain with motion, tenderness, or weakness of the cervical or thoracic sacrospinalis. She was observed to sit comfortably in typical masculine position crossing each leg and freely moving her head about with no objective signs of pain and no subjective complaints of pain. Range-of-motion testing of the cervical spine revealed full range of motion in flexion, extension, right and left lateral flexion, and in right and left rotation with no evidence of pain, crepitation, or instability. Following repetitive use, there was no additional limited range of motion of the cervical spine due to pain, fatigue, weakness, or lack of endurance. Range-of-motion testing of the lumbar spine revealed full range of motion in flexion, extension, right and left lateral flexion, and in right and left rotation with no evidence of pain, crepitation, or instability. Following repetitive use, there was no additional limited range of motion of the lumbar spine due to pain, fatigue, weakness, or lack of endurance. Motor, sensory, and reflex examination was reported as normal. Testing was conducted for non-organic physical signs, revealing positive Waddell's signs. The Veteran estimated that she lost four weeks from work during the last 12-month period due to back pain, neck pain, and headaches. She identified her usual occupation for 16 years as a full-time case worker in a clerical position for a rental assistance program with filing duties that result in neck and shoulder pain; she also stated that she was required to carry boxes of file folders down three flights of stairs, which resulted in low back pain. The examiner commented that there were no objective findings to correlate with any subjective complaints. The examining physician concluded that there were no significant effects on her occupation due to her cervical or lumbar spine disability. For the service-connected cervical and lumbar spine disability, the examining physician explained that pain was the appropriate diagnosis. He elaborated that cervical and lumbar x-rays were not indicated with musculoskeletal pain decades ago, neurologic function was normal, vascular status was normal, range of motion was normal, and there was no joint instability or other diagnosis. He cited numerous medical publications to support his conclusion that x-ray studies were not indicated. In April 2010, the Veteran testified that current treatment included monthly chiropractor and massage therapy visits and that missing those appointments exacerbates her back. She stated that she was last treated by her back doctor and physical therapist from August to October. She testified that she wakes most days in pain and takes a hot shower and does some stretches to try to loosen her spine. She reported stiffness in her cervical and lumbar spine, but mostly in the upper back where she could "feel the knots in there now." She stated that weight restrictions regarding lifting or bending were not necessary for the work that she does as a case worker, but working too much at the computer without getting up could affect her lower back. She testified that she could no longer shoot pool or play shuffle board due to her neck and back and it now took all day to clean her apartment instead of three hours. At the hearing, the Veteran submitted employee leave records dated from March 2009 through March 2010 in support of her claim; they reflected 158 hours of sick time used for herself. She also provided copies of receipts for massages and a copy of a March 2009 check addressed to C. Petrick for massage. In April 2010 the Veteran claimed entitlement to service connection for headaches and numbness in her right shoulder and arm, both claimed as secondary to the service-connected cervical spine disability. The RO denied the claims in an October 2010 rating decision and notified the Veteran of the decision in a separate letter dated the same month. The Veteran was afforded a VA spine examination in July 2010 to evaluate her service-connected neck and low back disorders. She described neck and shoulder pain as muscle tension and tightness, which she believed contributed to her headaches. She reported low back pain associated with any physical work whatsoever with no real shooting or radicular pain and no bowel or bladder issue. She reported stiffness, decreased motion, spasms, and cervical pain. She denied flare-ups, incapacitating episodes of spine disease, use of assistive devices, or limitations on walking. She indicated that she goes to a chiropractor, massage therapist, and physical therapist and that she essentially gets no exercise. She reported that she had dropped 30 pounds after she cut back on drinking; she was doing six to eight shots and six to eight beers a day, but stopped doing shots and was now having three to four beers a day most days. On physical examination, she had extremely poor posture and deconditioning of the shoulder girdle muscles with forward head position and postural thoracic kyphosis. Gait was normal. There was no cervical or thoracolumbar spine ankylosis. There was no spasm, atrophy, guarding, pain with motion, tenderness, or weakness of the cervical or thoracic sacrospinalis. There was no muscle spasm, localized tenderness, or guarding severe enough to be responsible for abnormal gait or abnormal spinal contour. Motor, sensory, and reflex examination was reported as normal. Range-of-motion testing of the cervical spine revealed flexion between 0 and 45 degrees, extension between 0 and 40 degrees, left lateral flexion to 40 degrees (rounded to the nearest 5 degrees), right lateral flexion to 45 degrees, left lateral rotation to 75 degrees (rounded to the nearest 5 degrees), and right lateral rotation to 80 degrees; the combined range of motion of the cervical spine was 325 degrees. There was objective evidence of pain on motion. Following repetitive motion, there were no additional limitations. Range-of-motion testing of the thoracolumbar spine revealed full range of motion in all planes with no objective evidence of pain on motion. Following three repetitions of range of motion, there were no additional limitations. The examiner indicated that testing for non-organic physical signs was conducted and three out of five were positive. Specifically, there was superficial and non-anatomic tenderness, failed distraction test of the cervical and lumbar spine, and over-reaction. Other significant physical examination findings were reported as pain behaviors and full effort in range of motion not apparent. Following a review of the claims file and physical examination, the diagnosis was history of service incurred acute whiplash injury; minimal degenerative disease of the cervical spine, not service incurred, not related to service injury; and myofascial, mechanical pain/strain of cervical spine and shoulder girdle, lifestyle related and not related to service injury. The examining physician opined that the spine pain was from deconditioning, postural issues, and abuse of analgesics and alcohol. There was no evidence that the Veteran's service-related strain was causing her current condition. The examiner stated that the service-related strain should have been self-limited and resolved, but there were clearly other lifestyle factors that were causal agents in the claimed conditions (regarding headaches and right shoulder and arm numbness). The examiner also indicated that she based her rationale on her review of the record, interview and physical examination of the Veteran, and clinical knowledge of chronic mechanical pain, as well as substance abuse as it relates to chronic pain. She emphasized that Waddell's examination was highly positive, indicating pain behaviors for secondary gain. In an August 2010 letter, the RO asked the Veteran to submit treatment records from Dr. Nachtman of Medical Associates that she mentioned during the hearing or to complete and return an enclosed VA Form 21-4142, Authorization and Consent to Release Information, to allow the RO to obtain the records on her behalf. She did not submit additional treatment records or return the completed form. The Board has considered the medical and lay evidence of record, but finds that a preponderance of the evidence is against the claim for a rating in excess of 10 percent for a cervical spine disability or for a lumbar spine disability. Regarding the cervical spine disability, it has been manifested at worst by a combined range of motion of the cervical spine of 325 degrees with pain on VA examination in July 2010. These findings are consistent with the 10 percent rating currently assigned under the General Rating Formula, which provides for a 10 percent rating for a combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees. A higher rating is not warranted because at no time has the Veteran's cervical spine disability been manifested by forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; or any ankylosis. Regarding the lumbar spine disability, it has been manifested by full range of motion without objective evidence of pain. These findings do not warrant a compensable rating because the medical evidence of record does not reflect forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height; or any ankylosis. Although the Board finds that a compensable rating for the lumbar spine disability is not warranted based on the medical evidence, the Board will not disturb the assigned 10 percent rating. Considering the Diagnostic Code 5243 based on incapacitating episodes, the Board finds that the 10 percent rating already assigned for each disability more than adequately compensates the Veteran for her cervical and lumbar spine disabilities. Although the Veteran provided employee leave records reflecting significant sick time used during a 12-month period, the medical evidence of record does not reflect diagnosed intervertebral disc syndrome of the lumbar spine or prescribed bed rest and treatment by a physician having a total duration of at least 2 weeks during a 12-month period. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Therefore, a rating in excess of 10 percent is not warranted on the basis of incapacitating episodes and the claim must be denied. The Board emphasizes that despite the Veteran's subjective complaints of chronic pain, decreased motion, and stiffness, the 10 percent ratings assigned for the cervical and lumbar spine disabilities appropriately compensate the Veteran for the extent of any functional loss due to limited or excess movement, pain, weakness, excess fatigability, and/or incoordination. See 38 C.F.R. §§ 4.40 and 4.45, and DeLuca. In this case, the December 2008 and July 2010 VA examination reports reflect that the Veteran was able to accomplish repetitive cervical and lumbar spine range-of-motion testing. Her range of motion of her neck or back, however, was not further limited by pain following repetition; nor was there evidence that range of motion was affected by fatigue, weakness, lack of endurance, or incoordination. Therefore, higher ratings would not be assignable for the cervical or lumbar spine disabilities based on any functional loss due to limited or excess movement, pain, weakness, excess fatigability, and/or incoordination. As a final matter, the Board has also considered whether the cervical or lumbar spine 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 an extraschedular rating is warranted for the disability on appeal. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are 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 disability level and symptomatology for her cervical and lumbar spine disabilities, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. Thus, her disability picture is contemplated by the rating schedule, and the assigned schedular ratings are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted for her cervical or lumbar spine disability. For all the foregoing reasons, the Board finds that the most probative and credible evidence does not support the assignment of a rating in excess of 10 percent for either the cervical spine disability or the lumbar spine disability at any point during the course of the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, entitlement to a higher rating for a cervical spine disability or a lumbar spine disability is not warranted, and the claims must be denied. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims for higher ratings, that doctrine is not helpful to the Veteran. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER A rating in excess of 10 percent for a cervical spine disability is denied. A rating in excess of 10 percent for a lumbar spine disability is denied. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs