Citation Nr: 1317677 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 06-00 065 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to a rating in excess of 30 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the right upper extremity. 2. Entitlement to a rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the left upper extremity. 3. Entitlement to a rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for right lower extremity peripheral neuropathy. 4. Entitlement to a rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for left lower extremity peripheral neuropathy. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran served on active duty from August 1963 to October 1984. This appeal comes to the Board of Veterans' Appeals (Board) from a December 2004 rating decision which granted service connection for peripheral neuropathy of the upper and lower extremities, with each segment rated at 10 percent, effective March 22, 2004. Thereafter, in a June 2009 rating decision, the disability rating for the Veteran's right upper extremity peripheral neuropathy was increased to 30 percent, effective October 6, 2009, and the ratings for his left upper extremity and bilateral lower extremity peripheral neuropathy were each increased to 20 percent, effective October 6, 2009. The RO subsequently made the effective dates for the increased ratings April 12, 2006. However, since the RO did not assign the maximum disability rating possible, the appeal for a higher rating remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In February 2009, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge sitting in San Antonio, Texas. A transcript of the hearing has been associated with the Veteran's claims folder. As noted in previous Board actions in July 2009, November 2010, and August 2012, the claim of entitlement to a total disability rating for compensation based on individual unemployability ("TDIU") has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction ("AOJ"). Therefore, the Board does not have jurisdiction over it and it is again referred to the AOJ for appropriate action. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The weight of the evidence shows that the Veteran's peripheral neuropathy of the right upper extremity (his major side) was first shown to be of moderate severity April 12, 2006, but was not shown to be more than mild in severity prior to that time or more than moderate in severity at any time during the course of the Veteran's appeal. 2. The weight of the evidence shows that the Veteran's peripheral neuropathy of the left upper extremity (his minor side) was first shown to be of moderate severity prior to April 12, 2006, but was not shown to be more than mild in severity prior to that time or more than moderate in severity at any time during the course of the Veteran's appeal. 3. The weight of the evidence shows that the Veteran's peripheral neuropathy of the right lower extremity was first shown to be of moderate severity prior to April 12, 2006, but was not shown to be more than mild in severity prior to that time or more than moderate in severity at any time during the course of the Veteran's appeal. 4. The weight of the evidence shows that the Veteran's peripheral neuropathy of the left lower extremity was first shown to be of moderate severity prior to April 12, 2006, but was not shown to be more than mild in severity prior to that time or more than moderate in severity at any time during the course of the Veteran's appeal. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8515 (2012). 2. The criteria for a rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8515 (2012). 3. The criteria for a rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2012). 4. The criteria for a rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the Court noted a distinction between an appeal involving the Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is propriety of the initial evaluations assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson, 12 Vet. App. at 126. With respect to the Veteran's service-connected peripheral neuropathy of the upper extremities, a distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. In the instant case, the record reflects the Veteran is right hand dominant; i.e., his right arm is the major upper extremity. The Veteran is currently seeking increased ratings for peripheral neuropathy of all four extremities, under 38 C.F.R. § 4.124a, Diagnostic Codes 8515 (upper extremities) and 8520 (lower extremities). Under Diagnostic Code 8515 when there is incomplete paralysis of the median nerve in the major extremity, 10, 30, and 50 percent ratings are assigned for mild, moderate and severe impairment respectively. When there is incomplete paralysis of the median nerve in the minor extremity, 10, 20, and 40 percent ratings are assigned for mild, moderate and severe impairment respectively. A 70 percent rating is assigned on the major side and a 60 percent rating is assigned on the minor side if there is complete paralysis of the median nerve with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; or pain with trophic disturbances. Under Diagnostic Code 8520 when there is incomplete paralysis of the sciatic nerve a 10 percent rating is assigned for mild impairment, a 20 percent rating is assigned for moderate impairment, a 40 percent rating is assigned for moderately severe impairment, and a 60 percent rating is assigned for severe impairment with marked muscular atrophy. An 80 percent rating is assigned for complete paralysis of the sciatic nerve where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a Words such as "mild", "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The rating schedule provides the following guidance in evaluating the severity of disabilities of peripheral nerves: Neuritis [cranial or peripheral] characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain [at times excruciating] is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. See 38 C.F.R. § 4.123. Neuralgia [cranial or peripheral] characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated as complete paralysis of the affected nerve. See 38 C.F.R. § 4.124 . As noted, the Veteran's claim for service connection was granted for each of the four extremities. The Veteran's rating has subsequently been increased with respect to each of his four extremities. As such, the Board must consider whether a rating in excess of 30 percent is warranted for the Veteran's right upper extremity, and whether ratings in excess of 20 percent are warranted for any of the other three extremities. The Board must also consider whether a rating in excess of 10 percent is warranted for the peripheral neuropathy in any of the Veteran's four extremities earlier than April 12, 2006. The Board will now turn to the rating criteria. As noted above, the Veteran's peripheral neuropathy of each extremity has been assigned multiple or "staged" ratings during the course of his appeal. This change in rating disability level is responsive to the fact that lay and medical evidence suggests that the Veteran's peripheral neuropathy has increased in severity during the course of his appeal. Thus, to appropriately rate the Veteran's service connected disabilities, the Board must separately consider the periods before and after April 12, 2006 when the Veteran's disability levels were increased. Period prior to April 12, 2006 As discussed above, prior to this time, the Veteran's peripheral neuropathy was rated as mild in each of his extremities. Having closely reviewed the medical and lay evidence of record, the Board concurs with this assessment, as the evidence of record prior to April 2006 shows wholly sensory involvement. For example, in March 2003, neurologic testing showed normal motor strength, sensation, deep tendon reflexes, and gait. Peripheral neuropathy was diagnosed in 2004, but even then neurologic testing did not show much impairment. A peripheral nerve examination was within normal limits. Neurological examination of the upper extremities showed normal motor testing, decreased sensation in the fingers, biceps and triceps jerk of 2+ bilaterally. Neurological examination of the lower extremities showed normal motor testing, decreased sensation in the feet, and reflexes of knee and ankle jerk of 2+ bilaterally. As such, while there was slight sensory involvement, motor testing was normal in all four extremities. In February 2005, the Veteran underwent a private neurological examination, but the doctor stated that a review of the neurological systems was otherwise unremarkable. The Veteran had normal gait and station, Romberg's sign was absent, and the Veteran was able to stand on toes and heels. Moreover, strength of both upper extremities was normal, 5/5. The Veteran had no clear or consistent sensory changes in the upper extremities, and strength was normal in his lower extremities. The Veteran was diagnosed with diffuse symmetric distal sensory peripheral neuropathy. In September 2005 the Veteran was seen again by Dr. Lim. It was noted that he was not symptomatic on the left side, except for the known carpal tunnel syndrome. The Veteran was diagnosed with distal symmetric sensory peripheral neuropathy. In January 2006, a needle electrode examination was normal, showing no evidence for a right cervical radiculopathy or brachial plexopathy. The Veteran was diagnosed with a rather mild diffuse peripheral neuropathy secondary to his diabetes mellitus, with a superimposed right median entrapment neuropathy of the wrists or carpal tunnel syndrome, and a right ulnar entrapment/pressure neuropathy at the elbow. In April 2006, the Veteran's rating was increased as the RO concluded that a private treatment record had first shown the presence of both sensory and motor impairment as a result of the peripheral neuropathy. However, prior to that point, as noted above, the Veteran's peripheral neuropathy was consistently described as mild, unremarkable, or even asymptomatic; moreover, the findings were wholly sensory in nature and motor impairment was not shown. As such, prior to April 12, 2006, the weight of the evidence does not support a finding of more than mild for the peripheral neuropathy in any of the Veteran's extremities. Current Evaluation The Board will now address the Veteran's peripheral neuropathy since April 12, 2006. As noted, his peripheral neuropathy has been rated as moderate in all four extremities since that time. In October 2006 the Veteran again saw Dr. Lim, asserting that the paresthesia of his hands was worsening, and his medication was changed to Gabapentin; yet, at his next visit in February 2007, Dr. Lim stated that the medication change appeared to be having some success. In fact, Dr. Lim stated that the Veteran's examination remained purely sensory, as strength remained normal in all four extremities. In May 2007, Dr. Soch wrote that the Veteran had developed "severe" peripheral neuropathy, but provided no explanation for why the peripheral neuropathy was considered to be severe; and again the use of terminology such as "severe" by medical professionals, although evidence to be considered by the Board, is not dispositive of an issue, as all evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Here, as will be discussed below, the Board takes Dr. Soch's categorization of "severe" to mean that the Veteran's peripheral neuropathy causes significant impairment. The Board does not dispute this fact, but concludes that the other medical findings do not support the classification of the Veteran's peripheral neuropathy as severe for VA rating purposes. For example, in June 2007, Dr. Lim acknowledged the significant neuropathic discomfort caused by the Veteran's peripheral neuropathy, noting that dosage of his Gabapentin had been increased. However, the Veteran had not experienced any adverse effects from the medication, and even he acknowledged that his medication was finally helping his symptoms. Again, Dr. Lim noted that the Veteran had only sensory changes as before, and found that there was no motor accompaniment and normal strength in all four extremities. As such, the finding of no motor impairment tends to undermine Dr. Soch's unsupported classification. Moreover, given Dr. Soch's suggestion, the Veteran was provided with a VA examination in August 2007, but this too failed to show more than moderate peripheral neuropathy in any of the Veteran's four extremities. For example, the examiner stated that a peripheral nerve examination was within normal limits. Neurological examination of the upper extremities showed abnormal motor function with a slightly weakened grip strength (4/5), there was also decreased sensation to tactile stimulation in both hands, and biceps and triceps jerk of 3+ bilaterally. Neurological examination of the lower extremities showed normal motor testing, decreased sensation to tactile and pain stimulation in the distal third of both legs, and reflexes of knee and ankle jerk of 3+ bilaterally. The examiner noted that the neurological condition resulted in neuritis. In January 2008, the Veteran was seen again by Dr. Lim for a prescription renewal. It was noted that he was no longer working, as his work had required him to stand all the time while lecturing and also required walking to check on inmates (however, the Veteran appears from to have subsequently returned to work per his wife's statement). The Veteran asserted that he was no longer able to mow his year on account of pain. On examination, the Veteran was totally areflexic, he had skinny legs that were felt to be out of proportion with his body build. Nevertheless, he had good strength in the upper extremities except for the small muscles of the hands that were 4-5/5, particular in the dorsal interossei. In the lower extremities, strength was normal at 5/5 proximally, but distally he had minor weakness of the dorsiflexors of both feet at 4-5/5 bilaterally. He also had sensory changes with decreased vibratory sensation up to the knees and stocking distribution hypesthesia. Dr. Lim explained that the Veteran's skinny legs were a result of his sensorimotor neuropathy. It was also noted that the Veteran was hampered by the severe discomfort from the neuropathic pain, requiring a high amount of Gabapentin, but he also had motor changes causing him to have the skinny legs and also weakness of the dorsiflexor of both feet, making it difficult for him to walk. Dr. Lim suggested that since the Veteran's condition was difficult to control, he could envision it eventually causing a foot drop or two. However, the medical evidence to date has not shown that that Veteran's peripheral neuropathy in his lower extremities has ever progressed to the point of causing foot drop. This treatment records does show the presence of motor impairment, in addition to the wholly sensory impairment that was previously shown, but it was in recognition of this fact that the moderate ratings were assigned. As such, the mere appearance of motor impairment does not mandate a higher rating. In February 2008, Dr. Soch asserted that the Veteran's peripheral neuropathy had progressed over the previous several years, and noted the Veteran's complaints of numbness, pain, and burning in both his hands, feet, and legs. Dr. Soch reported that the Veteran could not even walk a block on account of the pain. Based on this allegation of worsening, the Veteran was provided with another VA peripheral nerves examination was conducted in February 2008. The examiner noted both the earlier VA examination showing mild peripheral neuropathy and the extensive medication that the Veteran was prescribed for his peripheral neuropathy. The examiner noted that the Veteran's activities of working included prolonged standing and walking, both of which aggravated his already severe neuropathic pain. The Veteran asserted that he was unable to mow his lawn. The examiner noted that the Veteran had worked as a substance abuse counselor, but retired because he could not continue to work with prolonged standing on account of his foot pain. On examination, the Veteran's reflexes were1+ in the arms and 1.5+ in the knees and trace in the ankles. Sensory testing revealed diminished pin sensation over the fingers of both hands, compared to his forearms. The Veteran also experienced decreased pin sensation in the dorsum of his feet, and decreased vibratory sense in his feet. The examiner added that he was unable to dissociate the symptoms of the Veteran's ulnar neuropathy and carpal tunnel syndrome from the service connected peripheral neuropathy as they might be part of the overall peripheral neuropathy. In June 2008, the Veteran was seen by Dr. Lim, who noted that the Veteran's neuropathic discomfort was well-controlled with medication. However, the Veteran complained that he could not keep his right hand on the steering wheel because it would fall asleep. The Veteran denied any weakness and Tinel's sign was present over the median nerve at the wrist on both sides. Moreover, the Veteran did not have any sensory changes on the left. The Veteran had mild weakness on the right and normal on the left. There were only trace deep tendon reflexes in the upper extremities. The lower extremities were hypoactive, as the doctor could get a trace at the knees but not at the ankles. The Veteran had the usual stocking distribution hypesthesia. Dr. Lim stated that the Veteran had distal symmetric sensory peripheral neuropathy with superimposed bilateral median entrapment neuropathy at the wrist or carpal tunnel syndrome. At the time of the examination, the Veteran was only symptomatic on the right. The Veteran returned to Dr. Lim less than a month later complaining of bad neuropathic discomfort involving mostly a burning sensation in the soles of his feet, particularly on the left, which was aggravated by prolonged standing and walking. Dr. Lim explained that the pain was in direct proportion to his blood sugar control, but stated that the physical examination was essentially unchanged. In August 2008, Dr. Soch explained that the Veteran's poor sugar control had caused his diabetic peripheral neuropathy to become increasingly severe; and in January 2009, Dr. Tejeda suggested that the deterioration of the Veteran's glycemic control had led to worsening peripheral neuropathy. In January 2009, Dr. Lim also agreed that the Veteran's blood sugar was totally out of control, but observed that the Veteran's continuing neuropathic discomfort was fairly well-controlled with medication. The Veteran was noted to be having continued difficulty with his gait and his balance, due to the peripheral neuropathy; and walking caused pain, although the doctor suggested that this might be the result of vascular claudication from the diabetes mellitus. The Veteran's physical examination was unchanged. He was practically totally areflexic with the exception of the radial periosteal bilaterally at a trace. Strength was generally normal in all four extremities. He had stocking distribution hypesthesia and reduced vibratory sensation up to the knees. The Veteran was directed to continue with his medication. The Veteran was also provided with an additional VA examination in October 2009 to address the suggestion of possible worsening of his peripheral neuropathy. Motor strength was 5/5 in all four extremities without any atrophy or fasciculations. Reflexes were hypoactive throughout at +1 in the upper extremities, and at the knees and trace at the ankles. Sensory testing revealed decreased pin sensation in the palms of both hands and in the dorsum of his feet. Vibratory sense was also decreased in his fingers and toes. The examiner diagnosed peripheral neuropathy of the upper and lower extremities that was sensory in nature. The examiner found no evidence of paralysis, noting that the symptoms were sensory in nature with numbness and paresthesias and some foot discomfort. In August 2010, the Veteran underwent a VA examination for his diabetes mellitus at which a neurologic examination of the upper extremities showed motor functioning within normal limits, a sensory examination to pinprick, pain, touch, position, vibration, and temperature was intact bilateral. Biceps and triceps jerk was 2+ bilaterally. With regard to the lower extremities, motor function was also within normal limits, sensory function was abnormal on the right with regard to vibration (decreased stocking distribution). It was normal with regard to pinprick, pain, touch, position, vibration, and temperature. Ankle and knee jerks were 2+ bilaterally (normal). The examiner explained that there was no specific peripheral nerve identified as the Veteran presented with stocking distribution. There was sensory dysfunction demonstrated by the decreased vibration sense bilaterally in stocking distribution, but no motor dysfunction. The examiner stated that the Veteran had trouble standing and walking for prolonged periods due to his diabetic peripheral neuropathy. The Veteran used a cane to walk and tired easily. In September 2010, the Veteran's representative suggested that higher ratings were warranted for each of the Veteran's four extremities, but he gave no explanation as to why this was the case and he did not specifically identify any evidence that would support his contention. The Veteran was provided with another VA examination in January 2011 at which reflex testing showed 2+ distribution everywhere except ankle jerk which was absent. Sensory examination findings showed that the median sensory nerve on the right and left were affected. Vibration was normal, pinprick was decreased, position sense was normal, light touch was normal, and there was no dysesthesias. The peroneal sensory nerve in both lower extremities had decreased vibration, pinprick, position sense, and light touch, and dysesthesias. Motor testing was 5/5 in all four extremities. Muscle tone was normal and there was no muscle atrophy. The Veteran walked with a slight limp but there was no imbalance, tremor, or fasciculations. Moreover, the examiner opined that no joint functioning was affected by the Veteran's nerve disorder. An EMG/NCV was conducted in June which confirmed the diagnosis. There was nerve dysfunction, but not paralysis. In January 2013, the Veteran's claims file was returned to the VA examiner for clarification. The examiner explained that the finding at the January 2011 examination did not show any paralysis, and no muscle groups were affected by paralysis. The examiner explained that the EMG/NCV studies from February 2005 showed mild prolongation in the peroneal distal latencies and a mild reduction in nerve conduction in the peroneal nerves. Sural sensory responses were present and showed normal amplitudes and distal latencies. Sural conductions velocities were reduced. Median motor latencies were prolonged with normal overall conduction velocities. Median sensory responses were prolonged at both wrists. The left ulnar sensory amplitude was mildly reduced. Needle examination of the upper and lower extremities was normal, and all of the abnormalities were based on normative data from a large sample of normal individuals. The examiner explained that from the NCV studies, the Veteran did have some involvement in the peroneal nerves, but very minimally, because amplitudes are intact. The Veteran did appear to have greater involvement in the median nerves bilaterally, due to the prolonged medial responses. The examiner stated that he would rate the sensory neuropathy as mild in the lower extremities (due to the relative sparing of the sensory responses). The Veteran had focal median neuropathy in the wrists based on the finding of prolonged median motor and sensory latencies, which the examiner felt was moderate because of the prolonged distal latencies and mildly reduced amplitudes. The motor nerve involvement in the lower extremities was mild based on the NCV studies. The Veteran and his relatives have also submitted several statements in an effort to obtain a higher rating. In August 2008, the Veteran's wife wrote that he could not do exercise such as walking due to his neuropathy. She added that his daily activities were limited. She indicated that the Veteran had gone back to work, but it was difficult. She also noted that her husband's hands would go numb while driving which she felt was dangerous. She also asserted her belief that his conditions were worsening. The Veteran's daughter-in-law noted that simple tasks such as cutting grass, pushing a cart or standing/sitting for extended periods caused pain. She also noted that he had decreased sensation in his feet and hands, even when driving. The Veteran's step-son stated that the peripheral neuropathy in the Veteran's hands and feet made it difficult for him to perform chores such as yard work, or to carry items such as groceries. In the step-son's opinion, the Veteran's condition was deteriorating. In February 2009, the Veteran and his spouse testified at a hearing before the Board. He noted that his wife would drive on long stretches of highway when his hand starts going numb (after approximately 50 miles). The Veteran stated that he did a lot of typing for work as a Substance Abuse Counselor, suggesting that he had to stop and rest my hands causing the process took him three times as long as it would for a person without his condition. With regard to his legs, he reported feeling a lot of numbness, especially in his left leg. The Veteran's wife suggested that he was unable to do yard work or to get on a ladder. As noted, the Veteran was provided with several VA examinations to investigate his symptoms, but the multiple VA examinations have not shown severe peripheral neuropathy to be present in any of the Veteran's four extremities for any distinct period during the course of his appeal. There is no doubt that the Veteran's peripheral neuropathy causes impairment. To this end, both he and his wife credibly testified about the physical limitations caused by his peripheral neuropathy. However, some impairment with activities of daily living, including work, is precisely why the Veteran is provided with a compensable disability rating. That is, the Board acknowledges the fact that typing progress reports does take the Veteran longer than if he did not have peripheral neuropathy. However, the compensable ratings he is assigned for each of his four extremities is intended to help offset the slowing of work efficiency. Several medical professionals have suggested that the Veteran's peripheral neuropathy is severe, but have not provided any medical evidence to support such an assertion; and the Veteran has been provided with multiple VA examinations after each such assertion to investigate the allegations. These examinations have shown no atrophy to be present, and have regularly shown motor strength to be intact. The Veteran has had significant sensory impairment in all four extremities, but it is for this reason that the moderate ratings are assigned. Likewise, the Board has given particular attention to the testimony and lay statements by the Veteran's family, but finds that the objective medical evidence and testing does not show that a severe or moderately severe rating is warranted for any of the Veteran's four extremities. The Board does acknowledge that one VA examiner noted that the Veteran did experience neuritis. However, the moderate ratings that are assigned for the Veteran's peripheral neuropathy are within the range of ratings assignable when neuritis is present. That is, the rating schedule does not mandate a particular rating solely based on the presence, or absence, of neuritis. Given this conclusion, the Board finds that a higher schedular rating for the Veteran's peripheral neuropathy is denied. The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). 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. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's peripheral neuropathy that would render the schedular criteria inadequate. The Veteran's main symptoms are pain, tingling, numbness (essentially sensory impairment), as well as some periodic motor impairment. These are precisely the symptoms contemplated by the Diagnostic Codes for neurologic impairment. Moreover, the Diagnostic Codes for neurologic impairment use terms such as mild, moderate, and severe, etc, which provides the flexibility to take into account all of the symptoms attributed to the Veteran's neurologic impairment within the confines of the schedular rating which is assigned. As such, the schedular ratings that are assigned reasonably describe the Veteran's disability level and symptomatology, and referral for consideration of an extraschedular rating is not warranted. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. The Board acknowledges that the Veteran has not been employed for the entirety of his appeal. He has not, however, alleged that he is unemployable solely as a result of his peripheral neuropathy in his four extremities. Moreover, the Board has referred a claim for TDIU. Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability solely due to the Veteran's service connected disabilities on appeal. II. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In this case, the Veteran's claim for service connection for peripheral neuropathy of his four extremities was granted. He then appealed the downstream issues of the ratings that had been assigned. Under these circumstances, since the original claim was granted, there are no further notice requirements under the aforementioned law with regard to that issue. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In this case, private treatment records have been obtained, and the Veteran has not given any indication that he has received any VA treatment for his peripheral neuropathy. The Veteran also testified at a hearing before the Board; and was provided with several VA examinations (the reports of which have been associated with the claims file). There is no objective evidence indicating that there has been a material change in the severity of the Veteran's peripheral neuropathy since his most recent VA examination. Moreover, the Board has remanded the Veteran's claim on several occasions to ensure that his disabilities are/were rated on the most current evidence, and to ensure the adequacy of the VA examinations that were provided. To this end, a VA examination report was provided in January 2013, and the Veteran's representative acknowledged in an April 2013 brief that the responses to the Board's questions were provided. There was no allegation that this examination report was in any way inadequate. As such, the Board is satisfied that the development directed by the most recent remand was at the very least substantially complied with. Therefore, there is no prejudice for the Board to adjudicate this claim. See Stegall v. West, 11 Vet. App. 268 (1998). As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER A rating in excess of 30 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the right upper extremity is denied. A rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the left upper extremity is denied. A rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the right lower extremity is denied. A rating in excess of 20 percent, to include a rating in excess of 10 percent earlier than April 12, 2006, for peripheral neuropathy of the left lower extremity is denied. ____________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs