Citation Nr: 1320877	
Decision Date: 06/28/13    Archive Date: 07/05/13

DOCKET NO.  08-13 400	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina


THE ISSUES

1.  Entitlement to an initial rating greater than 10 percent prior to October 30, 2007, and greater than 30 percent thereafter, for bronchial asthma.

2.  Entitlement to an initial rating greater than 10 percent prior to January 30, 2012, and greater than 20 percent thereafter, for a lumbosacral spine disability (previously characterized as lumbosacral spine degenerative disc disease at L4-5 and L5-S1 with diffuse spondylosis).

3.  Entitlement to an initial compensable rating prior to July 10, 2006, and greater than 10 percent thereafter, for sinusitis.

4.  Entitlement to service connection for a bilateral wrist disability, to include as due to an undiagnosed illness.

5.  Entitlement to service connection for an eye disability, to include as due to an undiagnosed illness.



REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

Michael T. Osborne, Counsel


INTRODUCTION

The Veteran had active service from July 1981 to July 2005, including in the southwest Asia theater of operations during the Persian Gulf War.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, in which the RO granted, in pertinent part, the Veteran's claims of service connection for bronchial asthma, assigning a 10 percent rating effective August 1, 2005, a lumbosacral spine disability (which was characterized as lumbosacral spine degenerative disc disease at L4-5 and L5-S1 with diffuse spondylosis), assigning a zero percent rating effective August 1, 2005, and for sinusitis (which was characterized as chronic bilateral maxillary sinusitis), assigning a zero percent rating effective August 1, 2005.  The RO also denied the Veteran's claims of service connection for a bilateral wrist disability and for an eye disability.  The Veteran disagreed with this decision in July 2006, seeking higher initial ratings for her service-connected bronchial asthma, lumbosacral spine disability, and for sinusitis, and service connection for a bilateral wrist disability and for an eye disability.  The record evidence shows that the RO accepted a March 2008 letter from the Veteran as her substantive appeal on these claims in lieu of a VA Form 9.  Having reviewed the voluminous record evidence, the Board finds that the issues on appeal are characterized more appropriately as stated on the title page of this decision.

In a February 2008 rating decision, the RO assigned a higher initial 30 percent rating effective October 30, 2007, for the Veteran's service-connected bronchial asthma, a higher initial 10 percent rating effective August 1, 2005, for her service-connected lumbosacral spine disability, and a higher initial 10 percent rating for her service-connected bronchial asthma effective July 10, 2006.  In a June 2012 rating decision, the RO assigned a higher initial 20 percent rating effective January 30, 2012, for the Veteran's service-connected lumbosacral spine disability  Because the initial ratings assigned to these disabilities are not the maximum ratings available, all of these claims remains in appellate status.  See AB v. Brown, 6 Vet. App. 35 (1993).


FINDINGS OF FACT

1.  The record evidence shows that, prior to October 30, 2007, the Veteran's service-connected bronchial asthma is manifested by, at worst, intermittent inhalational or oral bronchodilator therapy (Albuterol).

2.  The record evidence shows that, effective October 30, 2007, the Veteran's service-connected bronchial asthma is manifested by, at worst, daily inhalational or oral bronchodilator therapy (Albuterol) or inhalational anti-inflammatory medication (Singulair and Advair).

3.  The record evidence shows that, prior to January 30, 2012, the Veteran's service-connected lumbosacral spine disability is manifested by, at worst, complaints of low back pain with flare-ups, forward flexion to 70 degrees with pain at 70 degrees, and tight paralumbar muscles.

4.  The record evidence shows that, effective January 30, 2012, the Veteran's service-connected lumbosacral spine disability is manifested by, at worst, flexion limited to 45 degrees, and additional limitation of motion to 40 degrees of forward flexion due to pain on repetitive range of motion testing. 

5.  The record evidence shows that, prior to July 10, 2006, the Veteran's service-connected sinusitis is manifested only by x-ray evidence of chronic bilateral maxillary sinusitis.

6.  The record evidence shows that, effective July 10, 2006, the Veteran's service-connected sinusitis is manifested by, at worst, 3 to 6 non-incapacitating episodes per year of sinusitis characterized by headaches, sinus pain, and purulent discharge or crusting. 

7.  The record evidence shows that the Veteran does not experience any current disability in the bilateral wrists or eyes which could be attributed to active service or any incident of service, to include as due to an undiagnosed illness.


CONCLUSIONS OF LAW

1.  The criteria for an initial rating greater than 10 percent prior to October 30, 2007, and greater than 30 percent thereafter, for bronchial asthma have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.97, Diagnostic Code (DC) 6602 (2012).

2.  The criteria for an initial rating greater than 10 percent prior to January 30, 2012, and greater than 20 percent thereafter, for a lumbosacral spine disability have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, DC 5243 (2012).

3.  The criteria for an initial compensable rating prior to July 10, 2006, and greater than 10 percent thereafter, for sinusitis have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.97, DC 6513 (2012).

4.  The criteria for service connection for a bilateral wrist disability, to include as due to an undiagnosed illness, have not been met.  38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2012).  

5.  The criteria for service connection for an eye disability, to include as due to an undiagnosed illness, have not been met.  38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined.  The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim.

In letters issued in August 2007 and in April 2008, VA notified the Veteran of the information and evidence needed to substantiate and complete her claims, including what part of that evidence she was to provide and what part VA would attempt to obtain for her.  See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002).  These letters informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of her claims.  The Veteran also was informed of when and where to send the evidence.  After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of her claims.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  Additional notice of the five elements of a service-connection claim was provided in the August 2007 and April 2008 VCAA notice letters, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

The Veteran's higher initial rating claims for bronchial asthma, a lumbosacral spine disability, and for sinusitis are "downstream" elements of the RO's grant of service connection for these disabilities in the currently appealed rating decision.  For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection.  See VAOPGCPREC 8-2003 (Dec. 22, 2003).  Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial.  Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007).  As noted, in August 2007 and in April 2008, VA notified the Veteran of the information and evidence needed to substantiate and complete her service connection claims, including what part of that evidence she was to provide and what part VA would attempt to obtain for her.  See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187.

As will be explained below in greater detail, the evidence does not support assigning higher initial ratings for the Veteran's service-connected bronchial asthma, lumbosacral spine disability, and sinusitis.  The evidence also does not support granting service connection for a bilateral wrist disability or an eye disability.  Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial.  See Bernard v. Brown, 4 Vet. App. 384, 394 (1993).  The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process.  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006).

With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  Although the Board acknowledges that the Veteran did not receive pre-adjudication VCAA notice in this case, because all of her claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot.  See Dingess, 19 Vet. App. at 473.  And any defect in the timing or content of the notice provided to the Veteran and her service representative has not affected the fairness of the adjudication.  See Mayfield, 444 F.3d at 1328.

The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, section § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life.  Relying on the informal guidance from VA's Office of General Counsel (OGC) and a VA Fast Letter issued in June 2008 (Fast Letter 08-16; June 2, 2008), the Board finds that Vazquez-Flores is not applicable.  According to OGC, because this case concerns an appeal from an initial rating decision, VCAA notice obligations are satisfied fully once service connection has been granted.  Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely NOD with respect to the initial rating or effective date assigned following the grant of service connection.

In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled.  Id., at 490-91.  To the extent that Dingess requires more extensive notice as to potential downstream issues such as disability rating and effective date, because the currently appealed rating decision was fully favorable to the Veteran on the issues of service connection for bronchial asthma, a lumbosacral spine disability, and sinusitis, and because the Veteran was fully informed of the evidence needed to substantiate these claims, the Board finds no prejudice to the Veteran in proceeding with the present decision.  See also Bernard v. Brown, 4 Vet. App. 384, 394 (1993).

The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording her the opportunity to give testimony before the RO and the Board, although she declined to do so.  It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise.  The Veteran's Virtual VA claims file has been reviewed and no relevant evidence was located there.  The Veteran also does not contend, and the evidence does not show, that she is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain her SSA records is required.

The Veteran has been provided with VA examinations which address the current nature and severity of her service-connected bronchial asthma, lumbosacral spine disability, and sinusitis.  She also has been provided with VA examinations which address the contended causal relationship between the claimed bilateral wrist and eye disabilities and active service.  38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006).  Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations.  Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision.  See also 38 C.F.R. §§ 3.326, 3.327, 4.2.  In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA.

Higher Initial Rating Claims

The Veteran contends that her service-connected bronchial asthma, lumbosacral spine disability, and sinusitis are all more disabling than currently evaluated.  She specifically contends that she experiences incapacitating sinus infections at least 3 times a year as a result of worsening service-connected bronchial asthma and service-connected sinusitis.  She also contends that she is unable to sit, walk, or drive a vehicle as a result of worsening service-connected lumbosacral spine disability.

In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1.  Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings.  The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history.  38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991).

Where, as in this case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time.  Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings.  See Fenderson v. West, 12 Vet. App. 119 (1999).

The Veteran's service-connected bronchial asthma currently is evaluated as 10 percent disabling prior to October 30, 2007, and as 30 percent disabling thereafter under 38 C.F.R. § 4.97, DC 6602.  See 38 C.F.R. § 4.97, DC 6602 (2012).  The Veteran's service-connected lumbosacral spine disability currently is evaluated as 10 percent disabling prior to January 30, 2012, and as 20 percent thereafter by analogy to 38 C.F.R. § 4.71a, DC 5243 (intervertebral disc syndrome).  See 38 C.F.R. § 4.71a, DC 5243 (2012).  The Veteran's service-connected sinusitis currently is evaluated as zero percent disabling (non-compensable) prior to July 10, 2006, and as 10 percent disabling thereafter under 38 C.F.R. § 4.97, DC 6513 (chronic maxillary sinusitis).  See 38 C.F.R. § 4.97, DC 6513 (2012). 

Under DC 6602, a 10 percent rating is assigned for bronchial asthma for Forced Expiratory Volume in one second (FEV-1) of 71 to 80 percent of predicted value, or the ratio of FEV-1 to Forced Vital Capacity (FVC) (FEV-1/FVC) of 71 to 80 percent, or intermittent inhalational or oral bronchodilator therapy.  A 30 percent rating is assigned for FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent or daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication.  A 60 percent rating is assigned for an FEV-1 of 40 to 55 percent predicted, or FEV-1/FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least 3 times per year) course of systemic (oral or parenteral) corticosteroids.  A maximum 100 percent rating is assigned under DC 6602 for bronchial asthma with an FEV-1 of less than 40 percent predicted, or FEV-1/FVC less than 40 percent, or more than 1 attack per week with episodes of respiratory failure, or requires daily use of systemic (oral or parenteral) high dose corticosteroids or immunosuppressive medications.  See 38 C.F.R. § 4.97, DC 6602 (2012).

Under DC 5243, intervertebral disc syndrome can be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine ("General Rating Formula") or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating.  In this case, the Veteran's service-connected lumbosacral spine disability has been rated under the General Rating Formula as that results in a higher rating.  Under the General Rating Formula, a 10 percent rating is assigned for lumbosacral spine disability manifested by forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or a 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.  A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine not greater than 120 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.  A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine.  A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine.  A maximum 100 percent rating is assigned for unfavorable ankylosis of the entire spine.  See 38 C.F.R. § 4.71a, DC 5243 (2012). 

Finally, DC 6513 provides that chronic maxillary sinusitis will be rated under the General Rating Formula for Sinusitis.  A zero percent (non-compensable) rating is assigned under DC 6513 for chronic maxillary sinusitis detected by x-ray only.  A minimum 10 percent rating is assigned for chronic maxillary sinusitis manifested by 1 or 2 incapacitating episodes per year of sinusitis requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment or 3 to 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  A 30 percent rating is assigned for chronic maxillary sinusitis manifested by 3 or more incapacitating episodes per year of sinusitis requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment or more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  A maximum 50 percent rating is assigned for chronic maxillary sinusitis following radical surgery with chronic osteomyelitis or near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus and purulent discharge or crusting after repeated surgeries.  See 38 C.F.R. § 4.97, DC 6513 (2012).

The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment.  38 C.F.R. § 4.10 (2012).  Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance.  38 C.F.R. § 4.40 (2012).  Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing.  For the purpose of rating disability from arthritis, the lumbar vertebrae are considered a group of minor joints ratable on a parity with major joints.  38 C.F.R. § 4.45 (2012).  VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the diagnostic codes; "functional loss" may occur as a result of weakness, fatigability, incoordination or pain on motion.  38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995).  VA must consider any part of the musculoskeletal system that becomes painful on use to be "seriously disabled."

If a Veteran has separate and distinct manifestations relating to the same injury, she should be compensated under different diagnostic codes.  Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993).  The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided.  38 C.F.R. § 4.14 (2012).  The Rating Schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomatology, since such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding.  See Esteban, citing Brady v. Brown, 4 Vet. App. 203 (1993).

Under 38 C.F.R. §§ 4.40 and 4.45, a Veteran's pain, swelling, weakness, and excess fatigability must be considered when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes.  See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court held in DeLuca that all complaints of pain, fatigability, etc., shall be considered when put forth by a Veteran.  Therefore, consistent with DeLuca and 38 C.F.R. § 4.59, the Veteran's complaints of pain have been considered in the Board's review of the diagnostic codes for limitation of motion.

Factual Background

The Veteran's voluminous service treatment records show that she complained of and was treated for bronchial asthma, a lumbosacral spine disability, and for sinusitis during her 24 years of active service.  For example, periodic physical examinations in October 1985, April 1987, and in May 1988 showed that the Veteran's sinuses, lungs and chest, and spine were clinically normal.  Repeated chest x-rays were normal.  The Veteran denied all relevant medical history.  She reported smoking 2 packs per day for 8 years in May 1988.  

On periodic physical examination in December 1993, clinical evaluation was normal.  No chest x-ray was conducted.  A chronic cough was noted in the summary of defects and diagnoses.

On outpatient treatment in May 1998, the Veteran's complaints included nasal congestion, rhinorrhea, paroxysmal nocturnal dyspnea, and a productive cough for 2-3 days.  Physical examination showed yellow nasal secretions and clear lungs bilaterally.  A computerized tomography (CT) scan of the Veteran's sinuses showed bilaterally maxillary and ethmoid sinusitis.  The assessment included sinusitis.

In July 1998, the Veteran complained of headaches, a cough associated with a sore throat, and stuffiness.  She smoked 1 pack per day.  Objective examination showed non-tender sinuses.  A CT scan showed left maxillary sinusitis with mucosal thickening.  The assessment was a history consistent with chronic sinusitis.

On September 15, 1998, the Veteran's complaints included sinus congestion for the previous 31/2 months.  She had a "cold that won't go away."  She also complained of rhinorrhea, nasal irritation, nasal congestion, cough, and paroxysmal nocturnal dyspnea.  Physical examination showed clear secretion in the nares and clear lungs bilaterally.  The assessment included chronic sinusitis.

On September 28, 1998, the Veteran complained of 1 day of low back pain.  Objective examination showed paraspinal muscle spasm, negative straight leg raising, a decreased range of motion secondary to pain, and no bowel or bladder dysfunction.  The assessment was mechanical back pain.

In December 1998, the Veteran complained of sinus congestion, headache, and a cough.  A history of rhinorrhea, paroxysmal nocturnal dyspnea, sinus pressure, and a cough was noted.  Objective examination showed sinus pressure on palpation and clear lungs bilaterally.  The assessment was sinusitis.

The Veteran had bilateral anterior ethmoidectomy in December 1998.  The pre-operative and operative diagnosis was chronic sinusitis.

The Veteran was seen in an Emergency Room (ER) in December 1999 for bilateral persistent chest pain which had lasted "off & on" for 3-4 days.  Objective examination showed a clear throat, and clear lungs bilaterally.  The assessment was asthma.

On periodic physical examination in January 2000, the Veteran's history included sinusitis, shortness of breath, pain or pressure in her chest, and a chronic cough.  A history of vasomotor sinusitis and chronic sinusitis also was noted.  Clinical evaluation showed bilateral wheezing in the lungs and a few scattered wheezes on increased air exchange.

On outpatient treatment on February 7, 2000, the Veteran complained of sinus congestion and shortness of breath.  Objective examination showed lungs clear to auscultation bilaterally and an FEV-1 which was 96 percent of predicted or normal.  The assessment was vasomotor rhinitis and shortness of breath.

On February 17, 2000, it was noted that the Veteran "continues to have congestion despite use of Claritin and Flonase."  The Veteran was not examined.  The assessment was mild persistent asthma "confirmed today" and vasomotor rhinitis.  The Veteran received a temporary physical profile later in February 2000 for asthma.

Following outpatient treatment in March 2000, the Veteran was diagnosed as having mild persistent asthma.

On outpatient treatment on July 12, 2000, the Veteran's complaints included sinus problems for the previous 2 days.  Objective examination showed she was in mild distress, an erythematous throat without exudate, and mildly tender maxillary sinuses.  The assessment included sinusitis.

On July 14, 2000, the Veteran's complaints included increased dry coughing, chest tightness, and difficulties sleeping secondary to coughing.  A history of asthma and reactive airway disease was noted.  Objective examination showed a normal pharynx, a slightly congested nose, and normal eyes and ears.  The Veteran's chest was clear to auscultation with tightness.  The assessment included reactive airway disease consistent with a history of asthma.

In October 2000, the Veteran complained of labored breathing, dry coughing with wheezing and shortness of breath since the night before, and nasal congestion.  She was a smoker.  Physical examination showed chest tightness, "wheezes off and on," no rhonchi or rales in the lungs, pharynx, tonsils, eyes, and ears normal, a congested nose, and a clear chest.  The assessment included asthma.

In November 2000, the Veteran's complaints included "tingling in bilateral arms," chest pain that was "a sharp pain not pressure" which "comes and goes."  Physical examination showed faint expiratory wheezing in the lungs.  The assessment included intermittent asthma.  The Veteran was advised to increase her use of albuterol and to stop smoking.

In May 2002, the Veteran complained of a morning sore throat, headache, congestion, a cough, sinus pain and pressure, and malaise.  Objective examination showed the Veteran was "mildly ill," congested, coughing, tender sinuses, a pink throat, non-enlarged tonsils, and a clear chest.  The assessment was sinusitis.

In March 2003, the Veteran complained of congestion, sinus pain and pressure, and a sinus infection twice a year.  Objective examination showed clear conjunctivae, tender right maxillary sinuses, a pink throat, non-enlarged tonsils, and a clear chest.  The assessment was right maxillary sinusitis.

On periodic physical examination in May 2003, the Veteran's history included asthma, shortness of breath, sinusitis, and recurrent back pain.  The in-service examiner noted that the Veteran's history of reactive airway disease had resolved with no inhaler use required.  Clinical evaluation was normal.  X-rays of the lumbosacral spine were grossly normal.

On outpatient treatment in September 2003, the Veteran's complaints included a cough and post-nasal drip.   A history of sinus infections and sinus surgery was noted.  Objective examination showed clear lungs without rhonchi, wheezes, or rales.  The assessment was sinusitis.

In January 2004, the Veteran complained of a sinus infection and stated that "antibiotics [were] not working."  Objective examination showed normal nasal mucosa, maxillary/frontal sinus tenderness, and clear lungs bilaterally with wheezing on forced expiration.  The assessment included sinusitis.

In February 2004, the Veteran's complaints included coughing up mucus the night before and mild shortness of breath.  Objective examination showed she was mildly ill, paroxysmal nocturnal dyspnea, purulent drainage in the bilateral nares, erythematous nasal mucosa, and lungs with wheezing, rales, and rhonchi.  The assessment included asthma exacerbation.

Chest x-rays taken in February and June 2004 was normal.

On outpatient treatment in March 2004, the Veteran's complaints included "coughing very hard" and "continuous" headaches.  She was taking Allegra twice a day.  Objective examination showed clear drainage in the bilateral nares, normal nasal mucosa, bilaterally maxillary/frontal sinus tenderness, and wheezing on forced expiration.  The assessment included sinusitis.

In May 2004, the Veteran's complaints included low back pain with occasional spasm from the back to the gluteal muscles.  Objective examination showed no spinous process tenderness, bilateral lumbosacral paraspinous tenderness to palpation radiating to the gluteal muscles, right greater than left, and negative straight leg raising.  Range of motion testing showed flexion to 80 degrees, extension to 5 degrees, with pain on lateral movement.  The assessment was lumbar strain.

In November 2004, the Veteran complaints of low back pain "worse in the past week or so" without bowel or bladder symptoms.  Objective examination showed she was able to climb on to the examination table without assistance, tender lumbar paraspinal muscles, a normal gait, and negative straight leg raising.  The assessment was low back pain.

At her separation physical examination in December 2004, clinical evaluation showed problems with flexion and extension of the lumbosacral spine, normal sinuses, and normal lungs and chest.  A chest x-ray was normal.  Low back pain and mild intermittent asthma that was controlled were noted in the summary of defects and diagnoses.  The Veteran reported a history of asthma, shortness of breath, bronchitis, wheezing, a chronic cough, sinusitis, chronic or frequent colds, and recurrent back pain.

On outpatient treatment in January 2005, the Veteran's complaints included continuing sinus pressure with green sputum and headaches.  A history of sinus surgery was noted.  Objective examination showed clear nares, boggy, erythematous nasal mucosa, bilaterally maxillary sinus tenderness, and clear lungs.  The assessment included sinusitis.

Private pulmonary function testing completed in February 2005 showed possible small airways disease.

In a February 2005 letter included in the Veteran's service treatment records, S.A.K., M.D., stated that the Veteran "has a ten year history of coughing, nasal congestion and postnasal drip.  The symptoms are daily and occur more often than not."  A history of "chronic sinusitis for many years" and mild asthma treated with albuterol also was noted.  "She has smoked one to two packs of cigarettes for twenty-three years and stopped in May of last year."  Physical examination showed pale nasal mucosa, no polyps or sinus tenderness, and a clear chest without rales, rhonchi, or wheezes.  The impressions were non-allergic rhinitis and sinusitis, a past history of smoking, and mild bronchial asthma.

A private magnetic resonance imaging (MRI) scan of the Veteran's lumbar spine taken in March 2005 and included in her service treatment records showed degenerative disc disease at L4-5 and L5-S1.

At a "pre-retirement" physical examination in March 2005, the Veteran's complaints included a nighttime cough.  It was noted that the Veteran recently had been diagnosed as having reactive airway disease.  A history of asthma also was noted.  The assessment included reactive airway disease, seasonal allergic rhinitis, and low back pain.

On VA examination in June 2005, approximately 1 month prior to her separation from service, the Veteran's complaints included low back pain since May 2004, sinusitis, and asthma since 1990.  The Veteran stated that her low back pain "does not interfere with her ordinary lifting or carrying, posture or gait.  There is no history of persistent radiation."  She was able to drive a car.  The Veteran's December 1998 sinus surgery was noted.  She was taking Claritin every day to treat her sinusitis "and that appears to maintain the condition without complications."  She had been taking Albuterol since being diagnosed as having asthma in 1990.  She also took short course antibiotics "during exacerbations" of asthma.  She currently took 2 puffs of Albuterol per week.  No history of cough, shortness of breath, or chest pain as noted.  "In general, she can sustain heavy physical activities without immediate distress."  Physical examination showed she was obese, no sinus tenderness, open nostrils, good air entry in both lungs "without adventitious sounds," a normal breathing pattern "without respiratory distress," normal gait and posture.  Physical examination of the lumbosacral spine showed a full range of motion without any DeLuca factors present, no parapinsal muscle spasm, maintained spinal curvature, no muscle atrophy, sensation within normal limits, negative straight leg raising bilaterally, and no radiating pain with movement.  X-rays of the lumbosacral spine showed minimal diffuse lumbar spondylosis and mild degenerative disc space narrowing L4-5 and L5-S1.  Pulmonary function testing showed FEV-1 of 79 percent of predicted value and FEV-1/FVC of 84 percent of predicted value.  The VA examiner stated that no spine pathology had been "identified on physical examination to render a diagnosis."  He also stated that there were no signs of any active, acute, or chronic sinus disease on physical examination.  He stated further that the Veteran's asthma was stable and without complications.  The diagnoses included diffuse lumbar spondylosis and mild degenerative disc space narrowing L4-5 and L5-S1 by x-ray, chronic bilateral maxillary sinusitis by x-ray, and stable bronchial asthma on treatment and without complication.

The post-service evidence shows that, on private pulmonary function testing conducted in February 2005, the Veteran's FEV-1 was 97 percent of predicted value and her FEV-1/FVC was 99 percent of predicted value.

On private outpatient physical therapy treatment in March 2006, the Veteran complained of chronic low back pain which had begun insidiously 2 years earlier.  The physical therapist stated that the Veteran's signs and symptoms were consistent with degenerative changes.  

On private outpatient treatment on May 17, 2006, the Veteran's complaints included low back pain and unstable asthma.  She had used Albuterol 3 times a day for 1-2 weeks.  Objective examination showed boggy and erythematous nasal turbinates, tender maxillary and frontal sinuses, and clear lungs bilaterally.  The assessment included severe persistent asthma and low back pain with radiation.

On May 25, 2006, the Veteran reported that her asthma was improving with Albuterol usage.  Objective examination showed clear lungs bilaterally.  The assessment included improving asthma.

On July 10, 2006, the Veteran's complaints included sinus congestion.  Objective examination showed pink, boggy, and erythematous nasal turbinates and non-tender sinuses.  The assessment included chronic allergic rhinitis.

On private x-rays of the Veteran's lumbar spine taken in August 2006, the impressions were L4-5, L5-S1 degenerative disc disease and facet joint osteoarthritis and no acute abnormality.

The Veteran was seen in the ER at a VA Medical Center later in August 2006 complaining of increasing low back pain for several days.  She denied any recent trauma, focal weakness, or bladder or bowel incontinence.  Physical examination showed pain elicited on motion of the back and a restricted range of motion.  The assessment was chronic low back pain.

On private outpatient treatment in December 2006, the Veteran's complaints included headaches and sinus infections with clear yellow drainage and sinus pain.  Objective examination showed boggy erythematous turbinates with discharge, tender frontal and maxillary sinuses, and post-nasal drip.  The assessment included sinusitis.

In February 2007, the Veteran complained of sinus problems and headaches.  She reported that she did well after sinus surgery "until the last 3 years."  She experienced 4-6 sinus infections per year.  She was using Flonase "at times" and had used Singulair in the past.  Physical examination showed a deviated nasal septum to the left, open ethmoid and maxillary sinuses on the right, no ostium on the left side, no purulence, and no tonsils.  The assessment included allergic rhinitis "cause unspecified" and unspecified chronic sinusitis.

A private CT scan of the Veteran's paranasal sinuses taken in March 2007 showed mild chronic sinusitis changes involving the left maxillary sinus.

On private outpatient treatment in April 2007, the Veteran's complaints included congestion "since Sunday," headaches for 4 days, a productive cough with purulent sputum, and sinus pain.  Objective examination showed boggy erythematous turbinates with discharge, tender frontal and maxillary sinuses, and post-nasal drip.  The assessment included maxillary sinusitis.

In a May 2007 letter, G.D., M.D., stated that he had seen the Veteran once in June 2006 with complaints of shortness of breath and precordial chest tightness.  A history of smoking 2 packs per day was noted.  "She quit several years ago."  The Veteran also "reported chronic postnasal drainage."  Physical examination showed bilateral air entry without rhonchi or rales.  A chest x-ray was not available for review.  Pulmonary function testing was within normal limits.  Dr. G.D. stated that he suspected the Veteran had chronic bronchitis/asthma.  He recommended treatment with Advair.

An MRI scan of the Veteran's lumbosacral spine taken in July 2007 showed no evidence of acute fracture, focal disc herniation or extrusion, degenerative disc disease and degenerative joint disease at L4-5 which resulted in moderate left sided neuroforaminal stenosis, and degenerative disc disease and degenerative joint disease at L5-S1 which resulted in moderate bilateral neuroforaminal stenosis. 

On private outpatient treatment in August 2007, the Veteran's complaints included back pain.  His MRI scan was noted.  Objective examination showed a decreased range of motion in the back.  The assessment included low back pain with radiation.

In October 2007, the Veteran's complaints included muscle spasms and tightness in the back.  Objective examination was unchanged.  The assessment included low back pain.

On VA respiratory examination on October 30, 2007, the Veteran complained of unstable asthma "meaning it flares-up frequently" and especially "when she has increased sinus problems with sinusitis."  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  The Veteran denied any productive cough.  She reported experiencing shortness of breath "and this was noted during the examination.  Getting up and down from the table she would be short of breath."  The Veteran also reported asthmatic attacks "about twice a week where she has to use an Albuterol inhaler.  She has not had to go to the emergency room for a nebulizer treatment.  She has more frequent attacks when she has sinusitis."  She was on Albuterol as needed "using this about twice a week," Singulair twice a day, and Advair twice a day.  She denied any periods of total incapacitation "but she does have periods where she cannot get about and do her usual activities because of asthma.  It is at those times that she uses her inhaler and this might last from several hours to a day or so."  Physical examination showed clear lungs with no wheezing, no evidence of cor pulmonale, reported weight gain "over the past three years since she stopped smoking," and no restrictive lung disease.  Pulmonary function testing showed an FEV-1 of 84 percent of predicted value and an FEV-1/FVC of 85 percent of predicted value.  The diagnosis was chronic unstable asthma.

On VA sinus examination in October 2007, the Veteran complained of chronic sinusitis.  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  A history of sinus surgery was noted which improved her sinusitis "but for the past three years she is having increasing problems."  The Veteran experienced 4-6 episodes of sinusitis flare-ups per year which required antibiotic treatment and were accompanied by maxillary facial pain.  She was incapacitated during these flare-sups for 4-5 days "until 'the antibiotics take effect.'"  An ears, nose, and throat (ENT) evaluation had confirmed chronic sinusitis.  An MRI had shown mild maxillary sinusitis.  There was some interference breathing through her nose when she was very congested.  She also experienced purulent discharge during a flare-up but not at this examination.  She was taking Claritin and using Astelin nasal spray and Flonase "for nasal congestion on an as needed basis."  The VA examiner stated that the Veteran's sinusitis "would not preclude her from working.  It does not interfere with her activities of daily living."  Physical examination showed a septal deviation to the left, no bacterial rhinitis, healthy nasal mucosa, mild obstruction "maybe 20-30% of the left nostril," an open and clear right nostril, no tissue loss, no sinus tenderness, no purulent discharge, no disease or injury affecting the soft palate, a normal voice, and a normal pharynx.  The VA examiner stated that the Veteran's "allergies affect her with nasal stuffiness and sneezing."  The diagnoses included chronic sinusitis.

On VA spine examination in October 2007, the Veteran's complaints included low back pain "going across the lower lumbar sacral area" and radiating down the right leg.  It worsened with activity and did not improve with resting or staying off of her feet.  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  A history of low back pain was noted.  The Veteran experienced flare-ups "with doing too much of anything."  She did not require any assistive devices.  Although the Veteran was unable to work due to her low back pain, the VA examiner noted that it did not interfere with her activities of daily living.  "She has episodes where she has to go to the emergency room for an injection but has not had episodes where she is completely incapacitated and confined to the bed."  Physical examination showed she was moderately obese, able to get up and down from a chair "fairly easily but has difficulty getting up and down from the supine position on the examining table doing this slowly and rolling to her side and pushing up," tight paralumbar muscles with marked increased tone, normal neurological examination, intact sensation, normal motor strength, and no postural abnormality.  Range of motion testing showed forward flexion to 70 degrees "where she has pain and would not go further.  She did repetitive movement to this point and there was no alteration in the range of motion.  She stopped after two repetitive movements because of pain."  Extension was to 10 degrees "and this was uncomfortable."  Lateral flexion was to 20 degrees bilaterally and lateral rotation was to 40 degrees bilaterally.  "These were done fairly easily without any significant pain."  The Veteran had objective evidence of painful motion "if she exceeds her range of motion."  Although the Veteran was able to stand on her heels and toes, "she could not walk across the room on her heels because of back pain."  The diagnosis was degenerative disc disease of the lumbar spine with radiculopathy.

The Veteran was seen in the ER at a VA Medical Center in December 2008 complaining of sinus pressure, headache, and sore throat, and a productive cough "for the past week."  Physical examination showed tenderness over the maxillary and frontal sinuses, midline septum, congested turbinates, clear lungs, and a steady gait.  The assessment included sinusitis and chronic low back pain.

On VA sinus examination in September 2009, the Veteran's complaints included recurrent episodes of sneezing, watering of eyes, and nasal congestion, although the VA examiner stated that "these are symptoms of allergic rhinitis, not sinusitis."  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  The Veteran's in-service sinus surgery was noted.  She stated that, since her in-service sinus surgery, she has "breathed better out of [her] nose and has less pressure in [her] face."  There was no history of incapacitating episodes of sinusitis although the Veteran reported a history of a 3-4 non-incapacitating episodes of sinusitis per year lasting 4-5 days and accompanied by headaches.  She experienced headaches twice a week and occasional breathing difficulty due to her sinusitis.  Physical examination showed no evidence of sinus disease, no signs of nasal obstruction, and "frontal and maxillary sinuses transilluminate well ruling out acute and chronic sinusitis."  X-rays showed normal sinuses.  The VA examiner stated that the Veteran's "allergic rhinitis and headaches have often been confused with sinusitis."  The diagnoses included no acute or chronic sinusitis.

On VA respiratory examination in December 2009, the Veteran complained of bronchial asthma.  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  The Veteran was on a daily inhaled bronchodilator and daily inhaled anti-inflammatory.  No parenteral steroids, antibiotics, or other immunosuppressive drugs were used.  The Veteran's current treatment relieved her symptoms.  She was on Albuterol 1-2 times a day and Advair twice daily.  She experienced a cough and wheezing up to several times daily.  She also experienced dyspnea occasionally on mild exertion and frequently on moderate and severe exertion.  A 22-year history of tobacco abuse was noted and she stopped smoking in 2003.  Physical examination showed no abnormal respiratory findings, normal diaphragm excursion and chest expansion, no chest wall scarring or deformity, no conditions associated with pulmonary restrictive disease, and mild impairment between asthma attacks.  Pulmonary function testing was normal.  The diagnoses were bronchial asthma and a 22-year history of tobacco abuse.

Following private outpatient treatment in February 2010, the Veteran was diagnosed as having improved sinusitis on medication.

The Veteran was seen in the ER at a VA Medical Center in March 2010 complaining of low back pain for 2 days "that has gotten worse today" and radiated through her buttocks to the left lower extremity.  She denied any bowel or bladder symptoms.  Physical examination showed tenderness over paraspinal muscles in the lumbar area.  The assessment was low back pain.

On private outpatient treatment in April 2010, the Veteran complained of chest congestion and a persistent cough.  Physical examination showed pink, boggy, and erythematous nasal turbinates, tender maxillary and frontal sinuses, and clear lungs without rales, rhonchi, or wheezes.  The assessment included sinusitis.

In May 2010, the Veteran's complaints included back pain.  She reported having an MRI in 2005 or 2006 "which did show evidence of some disk disease, but nothing has been done since then.  The pain in the low back persists all day long and gets worse when she is up on her feet.  At nighttime it may be worse, too.  The pain shoots down her right lower extremity, posterior thigh down to the calf, [and] down the leg."  The Veteran described her low back pain as "a sharp, shooting type of pain and at time it is very difficult to ambulate because of this."  Physical examination showed she was mildly obese, equal muscle bulk in all extremities, 5/5 muscle power in all extremities, normal sensation, normal finger-to-nose test, a slow gait, clear lungs, positive straight leg raising, and lumbar spine tenderness.  The assessment included a history of lumbar radiculopathy, sciatica on the right side.

A private MRI of the Veteran's lumbosacral spine taken in June 2010 showed degenerative disc disease and facet osteoarthritis at L3-4 through L5-S1 which resulted in symmetrical neural foraminal narrowing at L4-5 and L5-S1.  There was no central canal stenosis, acute osseous abnormality, or other focal disc pathology.

In a January 2011 statement, the Veteran contended that her service-connected lumbosacral spine disability had worsened "with pain radiating down [the] right leg."  She was unable to walk, sit, or drive a car "without pain for long periods of time."  She also contended that her service-connected asthma was stable on medication.

On VA spine examination in August 2011, the Veteran's complaints included flare-ups of low back pain radiating down her right leg.  She rated her low back pain during flare-ups as 8/10 on a pain scale (with 10/10 being the worst imaginable pain).  During flare-ups, she "has to lie down with a heating pad, take muscle relaxers, and cease all activity until the pain lessens.  The Veteran reports this usually takes 2-3 days."  Range of motion testing of the lumbosacral spine showed flexion to 85 degrees with objective evidence of painful motion beginning at 70 degrees, extension to 30 degrees with objective evidence of painful motion beginning at 30 degrees, lateral flexion to 30 degrees with objective evidence of painful motion beginning at 30 degrees in both directions, right lateral rotation to 25 degrees with objective evidence of painful motion beginning at 20 degrees, and left lateral rotation to 30 degrees with objective evidence of painful motion beginning at 30 degrees.  The Veteran was able to perform repetitive range of motion testing with no additional limitation of motion.  There was functional impairment of the thoracolumbar spine due to less movement than normal and pain on movement.  Physical examination showed localized tenderness or pain to palpation for the joints and/or soft tissues with reported tenderness over the paraspinal muscles in the lower lumbar area, no guarding or muscle spasm, 5/5 muscle strength, no muscle atrophy, normal reflexes and sensation, and negative straight leg raising.  There was moderate radicular pain of the right lower extremity and moderate involvement of the L2/L3/L4 nerve roots on the right side.  "The Veteran reports that she wears a maxi pad, that she changes approximately twice a day, due to urine saturation.  The Veteran also reports difficulty controlling bowels.  She does soil herself with stool incontinence intermittently, on average twice a month."  No intervertebral disc syndrome was present.  The Veteran did not use any assistive devices with ambulation.  X-rays of the lumbosacral spine showed degenerative joint disease and degenerative disc disease at the lower lumbar spine (L4-L5 and L5-S1), a mild broad-based posterior bulging disc at L5-S1 that was contiguous with the S1 nerve roots "without marked compression."  An MRI of the lumbar spine showed bilateral facet arthropathy with stenosis at L4-5, a broad-based posterior bulging disc at L5-S1 with bilateral facet arthropathy.  The Veteran stated that she was unable to lift anything weighing over 10 pounds.  She was able to perform sedentary work although some of the medications prescribed to treat her restless leg syndrome "make her sleepy."  The diagnosis was lumbar degenerative joint disease.

On VA respiratory examination in August 2011, the Veteran's complaints included asthma.  The VA examiner reviewed the Veteran's medical records although her claims file was not provided for review.  The Veteran's asthma had been stable since its onset and was treated with a daily inhaled bronchodilator and anti-inflammatory.  She took oral steroids intermittently up to 2 times per year for 1 week or less at a time.  "The Veteran describes taking a Medrol dose pack for flares."  She did not take any parenteral steroids.  She also took antibiotics up to 3 times per year.  A history of a non-productive cough, wheezing, dyspnea, non-anginal chest pain, night sweats, bronchiectasis, and asthma was noted.  The Veteran experienced a non-productive cough once or several times daily.  Her wheezing occurred a few times a year.  She experienced dyspnea on moderate exertion.  Her chest pain occurred at rest, on exertion, and "where a right rib fracture occurred previously."  She had 1-2 clinical visits per year for asthma and 1-2 acute asthma attacks per year.  Physical examination showed no evidence of abnormal breath sounds, normal diaphragm excursion and chest expansion, no conditions associated with pulmonary restrictive disease, and no chest wall scarring or deformity.  Pulmonary function testing showed a mild obstructive defect and no restrictive defect.  The diagnosis was asthma.

On VA sinus examination in August 2011, the Veteran complained of recurrent sinus infections 3-4 times per year, purulent nasal discharge, headaches, and sinus pain and tenderness.  Although the claims file was not available for review, the VA examiner reviewed the Veteran's medical records.  The Veteran reported a history of "chronic and recurrent sinus infections for several years" before undergoing sinus surgery in 1997.  She used Singulair and Zyrtec daily and 1 spray of Flonase in each nostril twice a day.  She also reported a history of seasonal nasal allergies.  Although a history of incapacitating episodes of sinusitis was reported, these episodes did not require 4-6 weeks of antibiotic treatment.  The Veteran experienced 3 non-incapacitating episodes of sinusitis per year each lasting 7-14 days with symptoms of headache, fever, purulent drainage, and sinus pain.  Physical examination showed no evidence of sinus disease, no signs of nasal obstruction, no nasal polyps, no septal deviation, no permanent hypertrophy of the turbinates from bacterial rhinitis, no rhinoscleroma, no tissue loss, scarring, or deformity of the nose, and no evidence of granulomatous infection.  The Veteran reported that she had retired in August 2005 because she was eligible due to her age or duration of work.  The VA examiner commented that "[t]hree sinus infections a year is considered a normal occurrence in the general population."  The diagnosis was sinusitis.  

On VA sinus examination in January 2012, the Veteran's complaints included chronic sinusitis.  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  The Veteran's sinusitis had no effect on her activities of daily living.  A history of sinus pain/tenderness and headaches was noted.  Physical examination showed clear lungs to auscultation and percussion, patent air flow in to the nose without obstruction, non-tender sinuses to palpation.  This examiner stated that the Veteran did not have sinus symptoms "at time of this exam."  

On VA asthma examination in January 2012, the Veteran's complaints included asthma.  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  The Veteran's asthma had been stable since its onset.  It was treated currently with Albuterol, Singulair, and Advair.  No oral or parenteral steroids or antibiotics were used.  There were no effects of the Veteran's sinusitis on her activities of daily living.  No diagnosis was rendered.

On VA spine examination on January 30, 2012, the Veteran's complaints included low back pain with standing or moving.  The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records.  Her low back pain was constant, mostly dull but sharp with flare-ups, mildly intense, started in the right lower back, and radiated down the right buttock to the right foot.  Her flare-ups of low back pain lasted for 1-3 months, occurred every 1-2 months, and were mild to moderate.  The Veteran was able to perform all of her activities of daily living independently.  Although she reported experiencing stress incontinence, "she has not been told that this is associated with her back problems."  She denied any associated bowel complaints.  She was able to walk between 1/4 mile and less than 1 mile.  She experienced incapacitating episodes of low back pain lasting 1 day "maybe twice in [the] past year."  Physical examination showed no strength deficits, normal thoracolumbar spine and posture, an antalgic gait, no spinal curvatures or ankylosis, no muscle spasm, no guarding, straight leg raising to 35 degrees on the right and to 40 degrees on the left.  Range of motion testing of the thoracolumbar spine showed flexion to 45 degrees, extension to 10 degrees, right lateral bending to 10 degrees, left lateral bending to 20 degrees, right rotation to 10 degrees, and left rotation to 15 degrees.  Following repetitive testing, the Veteran's thoracolumbar spine flexion was to 40 degrees and the remaining ranges of motion were unchanged.  An MRI of the lumbosacral spine was reviewed and showed degenerative joint disease and degenerative disc disease at L4-5 and L5-S1 and a mild broad-based bulging posterior disc at L5-S1 that was "contiguous with the S1 nerve roots."  The diagnoses included lumbosacral spine degenerative disc disease at L4-5 and L5-S1 and a mild broad-based bulging posterior disc at L5-S1.

In a September 2012 addendum to the VA examinations conducted in January 2012, the VA clinician stated that the Veteran's chronic sinusitis had no effect on his employability.  This clinician also stated that the Veteran's asthma was stable and she "may not be able to do certain jobs with increased exercise or in dusty places."  This clinician finally stated that the Veteran's lumbosacral spine disability was manifested by chronic pain, although stable, and the Veteran "may not be able to do physical work but could do sedentary work."  


Analysis

The Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating greater than 10 percent prior to October 30, 2007, and greater than 30 percent thereafter for bronchial asthma.  The Veteran has contended that her service-connected bronchial asthma is more disabling than currently (and initially) evaluated.  The record evidence does not support her assertions, however.  It shows instead that, prior to October 30, 2007, the Veteran's service-connected bronchial asthma is manifested by, at worst, intermittent inhalational or oral bronchodilator therapy (Albuterol).  The Board recognizes that the Veteran complained of and was treated for bronchial asthma during her 24 years of active service.  Her voluminous service treatment records show that she was diagnosed as having "mild persistent asthma" and placed on a temporary physical profile for asthma in February 2000.  She was diagnosed as having persistent asthma and advised to stop smoking and to increase her Albuterol usage in November 2000.  Clinical evaluation was normal on periodic physical examination in May 2003.  She experienced an asthma exacerbation in February 2004.  Her lungs were normal clinically at her separation physical examination in December 2004 when she reported an in-service history of asthma.  Dr. S.K. diagnosed the Veteran as having mild bronchial asthma in February 2005.  On VA examination in June 2005, prior to her separation from service in July 2005, her FEV-1 was 79 percent of predicted, her FEV-1/FVC was 84 percent of predicted value, and the Veteran was diagnosed as having stable bronchial asthma.  Following her service separation in July 2005, the Veteran's asthma had improved again on Albuterol on outpatient treatment in May 2006.  Dr. G.D. suspected that the Veteran was experiencing asthma after he saw her in May 2007.

The record evidence demonstrates that, prior to October 30, 2007, the Veteran's service-connected bronchial asthma is manifested by, at worst, intermittent inhalational or oral bronchodilator therapy (Albuterol).  The evidence does not indicate that the Veteran's bronchial asthma is manifested by an FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication (i.e., at least a 30 percent rating under DC 6602) such that an initial rating greater than 10 percent prior to October 30, 2007, is warranted for the Veteran's service-connected bronchial asthma.  See 38 C.F.R. § 4.97, DC 6602 (2012).  The Veteran appears to be compensated appropriately for the level of disability that she experienced during this time period as a result of her service-connected bronchial asthma.  She also has not identified or submitted any competent evidence demonstrating his entitlement to a higher initial rating for this disability prior to October 30, 2007.  In summary, the Board finds that the criteria for an initial rating greater than 10 percent prior to October 30, 2007, for the Veteran's service-connected bronchial asthma are not met.  Id.

The Board also finds that the preponderance of the evidence is against assigning an initial rating greater than 30 percent effective October 30, 2007, for the Veteran's service-connected right bronchial asthma.  The record does not demonstrate bronchial asthma manifested by an FEV-1 of 40 to 55 percent predicted, an FEV-1/FVC of 40 to 55 percent predicted, at least monthly visit to a physician for required care of exacerbations, or intermittent (at least 3 times a year) courses of systemic (oral or parenteral) corticosteroids such that an initial rating greater than 30 percent effective October 30, 2007, is warranted for this disability.  Id.  The evidence shows instead that, on VA examination on October 30, 2007, the Veteran reported asthmatic attacks "about twice a week where she has to use an Albuterol inhaler.  She has not had to go to the emergency room for a nebulizer treatment.  She has more frequent attacks when she has sinusitis."  She was on Albuterol as needed "using this about twice a week," Singulair twice a day, and Advair twice a day.  She denied any periods of total incapacitation "but she does have periods where she cannot get about and do her usual activities because of asthma.  It is at those times that she uses her inhaler and this might last from several hours to a day or so."  Physical examination showed clear lungs with no wheezing and no restrictive lung disease.  Pulmonary function testing showed an FEV-1 of 84 percent of predicted value and an FEV-1/FVC of 85 percent of predicted value.  

On VA respiratory examination in December 2009, the Veteran was on a daily inhaled bronchodilator and daily inhaled anti-inflammatory.  No parenteral steroids, antibiotics, or other immunosuppressive drugs were used.  The Veteran's current treatment relieved her symptoms.  She was on Albuterol 1-2 times a day and Advair twice daily.  She experienced a cough and wheezing up to several times daily.  She also experienced dyspnea occasionally on mild exertion and frequently on moderate and severe exertion.  A 22-year history of tobacco abuse was noted and she stopped smoking in 2003.  Physical examination showed no abnormal respiratory findings, normal diaphragm excursion and chest expansion, no chest wall scarring or deformity, no conditions associated with pulmonary restrictive disease, and mild impairment between asthma attacks.  Pulmonary function testing was normal.

In January 2011, the Veteran asserted that her service-connected asthma was stable on medication.

On VA respiratory examination in August 2011, the Veteran's asthma had been stable since its onset and was treated with a daily inhaled bronchodilator and anti-inflammatory.  She took oral steroids intermittently up to 2 times per year for 1 week or less at a time.  "The Veteran describes taking a Medrol dose pack for flares."  She did not take any parenteral steroids.  She also took antibiotics up to 3 times per year.  A history of a non-productive cough, wheezing, dyspnea, non-anginal chest pain, night sweats, bronchiectasis, and asthma was noted.  The Veteran experienced a non-productive cough once or several times daily.  Her wheezing occurred a few times a year.  She experienced dyspnea on moderate exertion.  Her chest pain occurred at rest, on exertion, and "where a right rib fracture occurred previously."  She had 1-2 clinical visits per year for asthma and 1-2 acute asthma attacks per year.  Physical examination showed no evidence of abnormal breath sounds, normal diaphragm excursion and chest expansion, no conditions associated with pulmonary restrictive disease, and no chest wall scarring or deformity.  Pulmonary function testing showed a mild obstructive defect and no restrictive defect.

On VA asthma examination in January 2012, it again was noted that the Veteran's asthma had been stable since its onset.  It was treated currently with Albuterol, Singulair, and Advair.  No oral or parenteral steroids or antibiotics were used.  There were no effects of the Veteran's sinusitis on her activities of daily living.  The VA examiner subsequently concluded in a September 2012 addendum to this examination report that the Veteran's asthma was stable.  

The record evidence demonstrates that, effective October 30, 2007, the Veteran's service-connected bronchial asthma is manifested by, at worst, daily inhalational or oral bronchodilator therapy (Albuterol) or inhalational anti-inflammatory medication (Singulair and Advair).  The Veteran herself contended in January 2011 that her service-connected bronchial asthma was stable on her current medication regimen.  This assertion is supported by the record evidence which shows that the Veteran's pulmonary function testing was normal in December 2009 and showed only a mild obstructive defect and no restrictive defect in August 2011.  Multiple VA clinicians have found since October 30, 2007, that the Veteran's service-connected bronchial asthma has been stable since its onset.  The January 2012 VA examiner also concluded that the Veteran's bronchial asthma was stable, no oral or parenteral steroids or antibiotics were used to treat it, and did not render a diagnosis following this examination.  The evidence does not indicate, and the Veteran does not contend, that her service-connected bronchial asthma is manifested by an FEV-1 of 40 to 55 percent predicted, an FEV-1/FVC of 40 to 55 percent, or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least 3 times per year) course of systemic (oral or parenteral) corticosteroids such that an initial rating greater than 30 percent effective October 30, 2007, is warranted.  See 38 C.F.R. § 4.97, DC 6602 (2012).  The Veteran appears to be compensated appropriately for the level of disability that she has experienced since October 30, 2007, as a result of her service-connected bronchial asthma as the record evidence supported assigning a 30 percent rating as of that date.  She has not identified or submitted any competent evidence demonstrating her entitlement to a higher initial rating than 30 percent for this disability effective October 30, 2007.  In summary, the Board finds that the criteria for an initial rating greater than 30 percent effective October 30, 2007, for the Veteran's service-connected bronchial asthma also are not met.      

The Board next finds that the preponderance of the evidence is against the Veteran's claim for an initial rating greater than 10 percent prior to January 30, 2012, and greater than 20 percent thereafter, for his service-connected lumbosacral spine disability.  The Veteran has contended that her service-connected lumbosacral spine disability is more disabling than currently (and initially) evaluated.  The record evidence does not support her assertions, however.  It shows instead that, prior to January 30, 2012, the Veteran's service-connected lumbosacral spine disability is manifested by, at worst, complaints of low back pain with flare-ups, forward flexion to 70 degrees with pain at 70 degrees, and tight paralumbar muscles.  The Board recognizes that the Veteran complained of and was treated for a lumbosacral spine disability (variously diagnosed as mechanical back pain, lumbar strain, low back pain, and degenerative disc disease at L4-S1) during her 24 years of active service.  

Her voluminous service treatment records show that she was diagnosed as having mechanical back pain following outpatient treatment in September 1998.  A periodic physical examination in May 2003 found her spine clinically normal and x-rays were normal.  The Veteran was diagnosed as having lumbar strain following outpatient treatment in May 2004 and low back pain following outpatient treatment in November 2004.  Her separation physical examination in December 2004 noted the presence of low back pain.  A private MRI conducted in March 2005 showed degenerative disc disease at L4-S1.  Finally, on VA examination in June 2005, just prior to her separation from service in July 2005, the Veteran stated that her low back pain "does not interfere with her ordinary lifting or carrying, posture or gait.  There is no history of persistent radiation."  She was able to drive a car.  "In general, she can sustain heavy physical activities without immediate distress."  Physical examination showed she was obese, normal gait and posture, a full range of motion in the lumbosacral spine without any DeLuca factors present, no parapinsal muscle spasm, maintained spinal curvature, no muscle atrophy, sensation within normal limits, negative straight leg raising bilaterally, and no radiating pain with movement.  X-rays of the lumbosacral spine showed minimal diffuse lumbar spondylosis and mild degenerative disc space narrowing L4-5 and L5-S1.  The VA examiner stated that no spine pathology had been "identified on physical examination to render a diagnosis."

Following her service separation in July 2005, private x-rays of the Veteran's lumbar spine taken in August 2006 showed L4-5, L5-S1 degenerative disc disease and facet joint osteoarthritis and no acute abnormality.  An MRI scan of the Veteran's lumbosacral spine taken in July 2007 showed degenerative disc disease and degenerative joint disease at L4-5 which resulted in moderate left sided neuroforaminal stenosis and degenerative disc disease and degenerative joint disease at L5-S1 which resulted in moderate bilateral neuroforaminal stenosis.

On VA examination in October 2007, the Veteran's complaints included low back pain "going across the lower lumbar sacral area" and radiating down the right leg.  It worsened with activity and did not improve with resting or staying off of her feet.  The Veteran experienced flare-ups "with doing too much of anything."  She did not require any assistive devices.  Although the Veteran was unable to work due to her low back pain, the VA examiner noted that it did not interfere with her activities of daily living.  "She has episodes where she has to go to the emergency room for an injection but has not had episodes where she is completely incapacitated and confined to the bed."  Physical examination showed she was moderately obese, able to get up and down from a chair "fairly easily but has difficulty getting up and down from the supine position on the examining table doing this slowly and rolling to her side and pushing up," tight paralumbar muscles with marked increased tone, normal neurological examination, intact sensation, normal motor strength, and no postural abnormality.  Range of motion testing showed forward flexion to 70 degrees "where she has pain and would not go further.  She did repetitive movement to this point and there was no alteration in the range of motion.  She stopped after two repetitive movements because of pain."  The Veteran had objective evidence of painful motion "if she exceeds her range of motion."  Although the Veteran was able to stand on her heels and toes, "she could not walk across the room on her heels because of back pain."

On VA spine examination in August 2011, the Veteran's complaints included flare-ups of low back pain radiating down her right leg.  She rated her low back pain during flare-ups as 8/10 on a pain scale.  During flare-ups, she "has to lie down with a heating pad, take muscle relaxers, and cease all activity until the pain lessens.  The Veteran reports this usually takes 2-3 days."  Range of motion testing of the lumbosacral spine showed flexion to 85 degrees with objective evidence of painful motion beginning at 70 degrees.  The Veteran was able to perform repetitive range of motion testing with no additional limitation of motion.  There was functional impairment of the thoracolumbar spine due to less movement than normal and pain on movement.  Physical examination showed localized tenderness or pain to palpation for the joints and/or soft tissues with reported tenderness over the paraspinal muscles in the lower lumbar area, no guarding or muscle spasm, 5/5 muscle strength, no muscle atrophy, normal reflexes and sensation, and negative straight leg raising.  There was moderate radicular pain of the right lower extremity and moderate involvement of the L2/L3/L4 nerve roots on the right side.  No intervertebral disc syndrome was present.  The Veteran did not use any assistive devices.  X-rays of the lumbosacral spine showed degenerative joint disease and degenerative disc disease at the lower lumbar spine (L4-L5 and L5-S1) and a mild broad-based posterior bulging disc at L5-S1 that was contiguous with the S1 nerve roots "without marked compression."  An MRI of the lumbar spine showed bilateral facet arthropathy with stenosis at L4-5, a broad-based posterior bulging disc at L5-S1 with bilateral facet arthropathy.

The record evidence demonstrates that, prior to January 30, 2012, the Veteran's service-connected lumbosacral spine disability is manifested by, at worst, complaints of low back pain with flare-ups, forward flexion to 70 degrees with pain at 70 degrees, and tight paralumbar muscles.  The evidence does not indicate that the Veteran's lumbosacral spine disability is manifested by forward flexion between 30 and 60 degrees, a combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such than an initial rating greater than 10 percent prior to January 30, 2012, is warranted.  See 38 C.F.R. § 4.71a, DC 5243 (2012).  The Veteran appears to be compensated appropriately for the level of disability that she experienced during this time period as a result of her service-connected lumbosacral spine disability.  She also has not identified or submitted any competent evidence demonstrating her entitlement to a higher initial rating for this disability prior to January 30, 2102.  In summary, the Board finds that the criteria for an initial rating greater than 10 percent prior to January 30, 2012, for the Veteran's service-connected lumbosacral spine disability are not met.  Id.

The Board also finds that the preponderance of the evidence is against assigning an initial rating greater than 20 percent effective January 30, 2012, for the Veteran's service-connected right lumbosacral spine disability.  The record does not demonstrate forward flexion 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine (i.e., a 40 percent rating under DC 5243) such that an initial rating greater than 20 percent effective January 30, 2012, is warranted for the Veteran's service-connected lumbosacral spine disability.  Id.  At the Veteran's most recent VA spine examination in January 2012, her complaints included low back pain with standing or moving.  Her low back pain was constant, mostly dull but sharp with flare-ups, mildly intense, started in the right lower back, and radiated down the right buttock to the right foot.  Her flare-ups of low back pain lasted for 1-3 months, occurred every 1-2 months, and were mild to moderate.  The Veteran was able to perform all of her activities of daily living independently.  Although she reported experiencing stress incontinence, "she has not been told that this is associated with her back problems."  She denied any associated bowel complaints.  She was able to walk between 1/4 mile and less than 1 mile.  She experienced incapacitating episodes of low back pain lasting 1 day "maybe twice in [the] past year."  Physical examination showed no strength deficits, normal thoracolumbar spine and posture, an antalgic gait, no spinal curvatures or ankylosis, no muscle spasm, no guarding, straight leg raising to 35 degrees on the right and to 40 degrees on the left.  Range of motion testing of the thoracolumbar spine showed flexion to 45 degrees.  Following repetitive testing, the Veteran's thoracolumbar spine flexion was to 40 degrees.

The Veteran appears to be compensated appropriately for the level of disability that she has experienced since January 30, 2012, as a result of her service-connected lumbosacral spine disability as the record evidence supported assigning a 20 percent rating as of that date.  She has not identified or submitted any competent evidence demonstrating her entitlement to a higher initial rating for this disability effective January 30, 2012.  In summary, the Board finds that the criteria for an initial rating greater than 20 percent effective January 30, 2012, for the Veteran's service-connected lumbosacral spine disability also are not met.  

The Board further finds that consideration of separate disability ratings for associated objective neurologic abnormalities, including bowel or bladder impairment, is not warranted.  See 38 C.F.R. § 4.71a, DC 5243, Note (1) (2012).  The Board acknowledges that, on VA examination in August 2011, the VA clinician stated, "The Veteran reports that she wears a maxi pad, that she changes approximately twice a day, due to urine saturation.  The Veteran also reports difficulty controlling bowels.  She does soil herself with stool incontinence intermittently, on average twice a month."  Although this suggests that the Veteran experienced bowel and bladder impairment, the August 2011 VA examiner did not find that this reported impairment was associated with the Veteran's service-connected lumbosacral spine disability.  More importantly, at her most recent VA examination in January 2012, although the Veteran reported experiencing stress incontinence, "she has not been told that this is associated with her back problems."  She denied any associated bowel complaints.  The Board notes in this regard that service connection currently is in effect for urinary stress incontinence, evaluated as 20 percent disabling, and for right lower extremity radiculopathy associated with her service-connected lumbosacral spine disability, evaluated as 20 percent disabling.  Thus, the Board finds that consideration of additional separate ratings for bowel or bladder impairment associated with the Veteran's service-connected lumbosacral spine disability is not warranted.

The Board finally finds that the preponderance of the evidence is against the Veteran's claim for an initial compensable rating prior to July 10, 2006, and greater than 10 percent thereafter, for sinusitis.  The Veteran has contended that her service-connected sinusitis is more disabling than currently (and initially) evaluated.  The record evidence does not support her assertions, however.  It shows instead that, prior to July 10, 2006, the Veteran's service-connected sinusitis is manifested only by x-ray evidence of chronic bilateral maxillary sinusitis.  The Board recognizes that the Veteran complained of and was treated for sinusitis during her 24 years of active service.  Her voluminous service treatment records show that she was diagnosed as having sinusitis following outpatient treatment in May 1998.  She was smoking 1 pack per day at that time.  The Veteran had sinus surgery in December 1998 to treat her sinusitis.  Repeated outpatient physical examinations of the Veteran's sinuses while she was on active service showed evidence of tender sinuses.  The Veteran reported taking Allegra twice a day and was diagnosed as having sinusitis following outpatient treatment in March 2004.  At her December 2004 separation physical examination, although she reported a history of sinusitis, physical examination showed normal sinuses.  Dr. S.K. concluded in February 2005 that the Veteran had sinusitis and noted a history of smoking 1-2 packs per day for 23 years which had stopped in May 2004.  The Veteran was diagnosed as having seasonal allergic rhinitis following outpatient treatment in March 2005.  Finally, on VA examination in June 2005, just prior to her separation from active service in July 2005, the Veteran reported taking Claritin every day to treat her sinusitis "and that appears to maintain the condition without complications."  She had been taking Albuterol since being diagnosed as having asthma in 1990.  She also took short course antibiotics "during exacerbations" of asthma.  She currently took 2 puffs of Albuterol per week.  No history of cough, shortness of breath, or chest pain as noted.  Physical examination showed no sinus tenderness, open nostrils, good air entry in both lungs "without adventitious sounds," and a normal breathing pattern "without respiratory distress."  Pulmonary function testing showed FEV-1 of 79 percent of predicted value and FEV-1/FVC of 84 percent of predicted value.  The VA examiner stated that there were no signs of any active, acute, or chronic sinus disease on physical examination.

The record evidence demonstrates that, prior to July 10, 2006, the Veteran's service-connected sinusitis is manifested only by x-ray evidence of chronic bilateral maxillary sinusitis.  The evidence does not indicate that the Veteran's sinusitis is manifested by 1 or 2 incapacitating episodes per year requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment or 3-6 non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting such than an initial compensable rating prior to July 10, 2006, is warranted.  See 38 C.F.R. § 4.97, DC 6513 (2012).  The Veteran appears to be compensated appropriately for the level of disability that she experienced during this time period as a result of her service-connected sinusitis.  She also has not identified or submitted any competent evidence demonstrating her entitlement to an initial compensable rating for this disability prior to July 10, 2006.  In summary, the Board finds that the criteria for an initial compensable rating prior to July 10, 2006, for the Veteran's service-connected sinusitis are not met.  Id.

The Board also finds that the preponderance of the evidence is against assigning an initial rating greater than 10 percent effective July 10, 2006, for the Veteran's service-connected sinusitis.  The record does not demonstrate 3 or more incapacitating episodes per year requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment or more than 6 non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting such that an initial rating greater than 10 percent effective July 10, 2006, is warranted for the Veteran's service-connected sinusitis.  Id.  It appears that, beginning on July 10, 2006, the Veteran's service-connected sinusitis was manifested by several episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or  crusting (i.e., a 10 percent rating under DC 6513).  Id.  The Board acknowledges that, although the Veteran reported on outpatient treatment in February 2007 that she experienced 4-6 sinus infections per year, the private clinician who treated her for sinusitis did not provide an opinion at that time as to whether these reported sinus infections were incapacitating.  A subsequent CT scan of the Veteran's paranasal sinuses taken 1 months later in March 2007 showed only mild chronic sinusitis changes involving the left maxillary sinus.

On VA sinus examination in October 2007, the Veteran reported experiencing 4-6 episodes of sinusitis flare-ups per year which required antibiotic treatment and were accompanied by maxillary facial pain.  She also reported being incapacitated during these flare-ups for 4-5 days "until 'the antibiotics take effect.'"  An MRI had shown mild maxillary sinusitis.  There was some interference breathing through her nose when she was very congested.  She also experienced purulent discharge during a flare-up but not at this examination.  She was taking Claritin and using Astelin nasal spray and Flonase "for nasal congestion on an as needed basis."  Physical examination showed no bacterial rhinitis, healthy nasal mucosa, mild obstruction "maybe 20-30% of the left nostril," an open and clear right nostril, no sinus tenderness, and no purulent discharge.

On VA sinus examination in September 2009, there was no history of incapacitating episodes of sinusitis reported although the Veteran reported a history of 3-4 non-incapacitating episodes of sinusitis per year lasting 4-5 days and accompanied by headaches.  She experienced headaches twice a week and occasional breathing difficulty due to her sinusitis.  Physical examination showed no evidence of sinus disease, no signs of nasal obstruction, and "frontal and maxillary sinuses transilluminate well ruling out acute and chronic sinusitis."  X-rays showed normal sinuses.  The VA examiner stated that the Veteran's "allergic rhinitis and headaches have often been confused with sinusitis."  The diagnoses included no acute or chronic sinusitis.

On VA sinus examination in August 2011, the Veteran reported a history of "chronic and recurrent sinus infections for several years" before undergoing sinus surgery in 1997.  She used Singulair and Zyrtec daily and 1 spray of Flonase in each nostril twice a day.  Although a history of incapacitating episodes of sinusitis was reported, these episodes did not require 4-6 weeks of antibiotic treatment.  The Veteran experienced 3 non-incapacitating episodes of sinusitis per year each lasting 7-14 days with symptoms of headache, fever, purulent drainage, and sinus pain.  Physical examination showed no evidence of sinus disease.  The VA examiner commented that "[t]hree sinus infections a year is considered a normal occurrence in the general population."  The diagnosis was sinusitis.  

At her most recent VA sinus examination in January 2012, it was noted that the Veteran's sinusitis had no effect on her activities of daily living.  A history of sinus pain/tenderness and headaches was noted.  Physical examination showed clear lungs to auscultation and percussion, patent air flow in to the nose without obstruction, and non-tender sinuses to palpation.  The VA examiner stated that the Veteran did not have sinus symptoms "at time of this exam."

The record evidence demonstrates that, effective July 10, 2006, the Veteran's service-connected sinusitis is manifested by, at worst, 3 to 6 non-incapacitating episodes per year of sinusitis characterized by headaches, sinus pain, and purulent discharge or crusting.  The evidence does not indicate that the Veteran experiences 3 or more incapacitating episodes of sinusitis per year requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment or more than 6 non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting such that an initial rating greater than 10 percent effective July 10, 2006, is warranted.  See 38 C.F.R. § 4.97, DC 6513 (2012).  The VA examiner concluded in August 2011 that the Veteran's reported 3 episodes of sinusitis per year was "normal."  The more recent evidence also suggests that the Veteran does not experience any current disability due to her service-connected sinusitis as there were no sinus symptoms present at the time of her January 2012 VA examination.  The Veteran appears to be compensated appropriately for the level of disability that she has experienced since July 10, 2006, as a result of her service-connected sinusitis as the record evidence supported assigning a 10 percent rating as of that date.  She has not identified or submitted any competent evidence demonstrating her entitlement to a higher initial rating than 10 percent for this disability effective July 10, 2006.  In summary, the Board finds that the criteria for an initial rating greater than 10 percent effective July 10, 2006, for the Veteran's service-connected sinusitis also are not met.

The Board finally finds that consideration of additional staged ratings is not warranted for any of the service-connected disabilities currently on appeal.  As discussed above, the Veteran is compensated appropriately for the level of disability that she experiences due to each of these service-connected disabilities for each of the time periods considered on appeal.  And it appears that higher initial ratings were assigned to each of these disabilities because of the worsening symptomatology that he experienced as of the dates that such ratings were assigned.  Thus, consideration of additional staged ratings is not warranted for any of the service-connected disabilities currently on appeal.  See Fenderson, 12 Vet. App. at 119.

Extraschedular

The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected bronchial asthma, lumbosacral spine disability, or sinusitis.  38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record).

An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996).  An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008).  If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization.  Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required.  38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116.

The Board finds that schedular evaluations assigned for the Veteran's service-connected bronchial asthma, lumbosacral spine disability, and sinusitis are not inadequate in this case.  Additionally, the diagnostic criteria adequately describe the severity and symptomatology of each of these service-connected disabilities.  This is especially true because each of the higher initial ratings assigned for these service-connected disabilities reflected a worsening of the relevant symptomatology (as discussed above).  Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization.  As noted above, the VA clinician stated in September 2012 that the Veteran's chronic sinusitis had no affect on his employability.  This clinician also stated that the Veteran's asthma was stable and she "may not be able to do certain jobs with increased exercise or in dusty places."  This clinician finally stated that the Veteran's lumbosacral spine disability was manifested by chronic pain, although stable, and the Veteran "may not be able to do physical work but could do sedentary work."  It does not appear that the Veteran was hospitalized for treatment of these service-connected disabilities during the pendency of this appeal.  In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met.  See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995).

Service Connection Claims

The Veteran contends that she incurred a bilateral wrist disability and an eye disability during active service.  She alternatively contends that she incurred disabilities of the wrists and eyes as a result of an undiagnosed illness experienced during the Persian Gulf War.

Law and Regulations

Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability.  Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999).

Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016.  38 C.F.R. § 3.317(a)(1)(i) (2012).  See also 76 Fed. Reg. 81834 (Dec. 29, 2011).  A "Persian Gulf Veteran" is one who served in the Southwest Asia theater of operations during the Persian Gulf War.  Id.  

Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification.  Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic.  The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest.  A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States.  38 C.F.R. § 3.317(a)(2)-(5).

Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended.  38 U.S.C.A. §§ 1117, 1118.  Essentially, these changes revised the term "chronic disability" to "qualifying chronic disability," and involved an expanded definition of "qualifying chronic disability" to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection.  38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317.  The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.  Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained.  38 C.F.R. § 3.317(a)(2)(ii).  

With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service.  Gutierrez v. Principi, 19 Vet. App. 1 (2004).  Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders.  38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b).

Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined.  VAOPGCPREC 8-98 (Aug. 3, 1998).  Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis.  The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317.  Id.

If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim.  See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997).  Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.  Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent.  If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology.  See Savage, 10 Vet. App. at 495-498.

In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a).  Because a bilateral wrist disability and an eye disability are not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to these claims.

It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case.  When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant.  Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility.  See 38 C.F.R. § 3.102.

Factual Background

The Veteran's voluminous service treatment records show that, on periodic physical examination in October 1985, clinical evaluation of the eyes and upper extremities was normal.  The Veteran's visual acuity was 20/40 correctable to 20/20 in the right eye and 20/20 in the left eye.  She denied all relevant medical history.  She reported wearing glasses or contact lenses which was attributable to her myopia since age 13.

On periodic physical examination in April 1987, clinical evaluation of the Veteran's eyes and upper extremities was normal.  The Veteran's visual acuity was 20/40 correctable to 20/20 in the right eye and 20/20 in the left eye.  She denied all relevant medical history.

On periodic physical examination in May 1988, clinical evaluation of the Veteran's eyes and upper extremities was normal.  The Veteran's visual acuity was 20/400 correctable to 20/20 in both eyes.  She denied all relevant medical history.  Myopia in the right eye was noted in the summary of defects and diagnoses.  

On periodic physical examination in December 1993, clinical evaluation of the Veteran's ears and upper extremities was normal.  Defective vision was noted in the summary of defects and diagnoses.

On periodic physical examination in January 2000, the Veteran denied any history of swollen or painful joints and eye trouble.  Clinical evaluation of the eyes and upper extremities was normal.  The Veteran's visual acuity was 20/400 correctable to 20/20 in both eyes.

At her separation physical examination in December 2004, clinical evaluation showed pain at the anterior aspect of the bilateral wrists and normal eyes.  The Veteran's visual acuity was 20/400+ correctable to 20/20 in both eyes.  Bilateral wrist pain was noted in the summary of defects and diagnoses.  The Veteran's history included eye trouble and a loss of vision.

On VA eye examination in June 2005, just prior to her separation from active service in July 2005, it was noted that the Veteran "presents without any complaint and states that her vision is good."  A history of "an infection two years ago where her left lid swelled up" was noted.  She wore contact lenses "on a cosmetic basis."  The Veteran's uncorrected visual acuity was 20/400 in both eyes.  Physical examination showed pupils equal, round, and reactive to light and accommodation, equal and full and normal visual fields in both eyes, full confrontation fields in both eyes, full extraocular muscles in both eyes, no double vision, normal intraocular pressure, external examination within normal limits, clear lids, lashes, conjunctiva, cornea, tear film, irises, and anterior chambers in both eyes, and "mild nuclear opacities of a congenital nature" in both eyes.  The assessment was simple myopia and compound myopic astigmatism and choroidal nevi in both eyes which did not present "any ocular problem and warrants annual observation."

On VA general medical examination in June 2005, the Veteran complained of bilateral wrist pain since November 2004.  She reported being told that she had arthritis in the wrists.  The Veteran's bilateral wrist pain did not interfere with her activities of daily living.  Physical examination of the wrists showed no heat, redness, tenderness, effusion, or muscle atrophy, normal tendon function, and undisturbed sensory perception and vascular supply of the hands.  There was a full range of motion in both wrists with no DeLuca factors present.  X-rays were negative.  The VA examiner concluded that there was no bilateral wrist pathology "identified on physical examination to render a diagnosis."

The post-service evidence shows that, on private outpatient treatment in September 2006, the Veteran's complaints included bilateral wrist pain which had lasted for 7 days and felt like "pins + needles."  Objective examination showed a decreased range of motion of the bilateral upper extremities.  The assessment included bilateral carpal tunnel.

In November 2006, the Veteran's complaints included wrist joint stiffness.  The assessment included carpal tunnel syndrome.

In January 2007, the Veteran's complaints included right hand trigger finger.  Objective examination showed a decreased range of motion of the right upper extremity.  The assessment included bilateral carpal tunnel.

A private electromyograph (EMG) taken in March 2007 showed a mild, focal, right median neuropathy at the wrist (carpal tunnel syndrome) without denervation.

In a March 2008 statement, the Veteran contended that she had experienced bilateral wrist pain since November 2004 and had been told that she had arthritis at her separation physical examination.  She also contended that her right wrist was worse than her left wrist.

On VA outpatient treatment in April 2009, the Veteran's complaints included bilateral wrist "aching" which had lasted for years.  Physical examination of the wrists showed tenderness over the bilateral wrist flexor/extensors and a full range of motion.  The assessment included wrist flexor/extensor tendonitis likely due to repetitive injury with keyboard work and house cleaning.  The Veteran had wrist splints and was advised to use them when on the computer.

A private EMG taken in May 2010 showed mild-moderate median nerve compression at the wrists bilaterally, no evidence of ulnar wave compression at the wrists, and no acute or chronic changes.

On VA examination in January 2012, the Veteran denied that she experienced an eye condition or any problems with her bilateral wrists.  No examination of either her eyes or wrists was conducted by the VA examiner.

Analysis

The Board finds that the preponderance of the evidence is against the Veteran's claims of service connection for a bilateral wrist disability and for an eye disability, each to include as due to an undiagnosed illness.  The Board notes initially that, because the Veteran's service personnel records (in this case, her DD Form 214) indicate that she served in the southwest Asia theater of operations during the Persian Gulf War, she is considered a "Persian Gulf Veteran" for VA compensation purposes.  38 C.F.R. § 3.317(a)(1)(i) (2012).  The Veteran has contended that she incurred disabilities of the wrists and eyes while on active service, to include as due to an undiagnosed illness.  The record evidence does not support her assertions concerning in-service incurrence of either of these disabilities, however.  It shows instead that, although the Veteran's visual acuity worsened during her 24 years of active service, her eyes were normal on repeated clinical evaluations.  Bilateral wrist pain also was noted at the Veteran's separation physical examination in December 2004.  The Board recognizes that a lack of service treatment records documenting in-service complaints of or treatment for bilateral wrist or eye disabilities does not preclude granting service connection.  See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms").  The Board notes in this regard, however, that, although bilateral wrist pain was noted in December 2004, several months prior to the Veteran's service separation, there was no bilateral wrist pathology present sufficient to render a diagnosis on VA general medical examination in June 2005, approximately 1 month prior to her service separation in July 2005.  The Board also recognizes that the presence of a mere symptom (such as bilateral wrist pain) alone, absent evidence of a diagnosed medical pathology or other identifiable underlying malady or condition that causes the symptom, does not qualify as disability for which service connection is available.  See generally Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001).  

Critically, the record evidence indicates that the Veteran does not experience any current bilateral wrist or eye disability which could be attributed to active service, to include as due to an undiagnosed illness.  An eye examination conducted in June 2005 approximately 1 month prior to the Veteran's separation from service in July 2005 showed only myopia which is defined as a refractive error of the eye.  See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1215 (30th ed. 2003).  The Board notes in this regard that service connection is prohibited for congenital defects including refractive error of the eye.  See 38 C.F.R. § 4.9 (2012).  Following VA general medical examination in June 2005, a different VA examiner concluded that the Veteran did not experience any bilateral wrist pathology sufficient to render a diagnosis.  In April 2009, a VA clinician attributed the Veteran's bilateral wrist flexor/extensor tendonitis to a repetitive injury with keyboard work and house cleaning.  Although subsequent outpatient treatment records indicate the presence of bilateral carpal tunnel syndrome, the Veteran specifically denied experiencing any bilateral wrist disability at her most recent VA examination in January 2012.  She also specifically denied experiencing any eye disability at this examination.

A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability.  Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced either a bilateral wrist disability or an eye disability at any time during the pendency of this appeal.  Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic.  McClain v. Nicholson, 21 Vet. App. 319 (2007).  In this case, there is no evidence of an eye disability (other than myopia which is considered a congenital defect) at any time during the pendency of this appeal that could be attributable to active service, to include as due to an undiagnosed illness.  Although there is evidence of a bilateral wrist disability, the record evidence indicates that it is not related to active service.  In summary, the Board finds that service connection for a bilateral wrist disability and for an eye disability is not warranted.

In this decision, the Board has considered all lay and medical evidence as it pertains to the issue.  38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence").  In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  

Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify").  A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses.  Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation).  Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a bilateral wrist disability and an eye disability fall outside the realm of common knowledge of a lay person.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer).

The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence.  See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303.  In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment.  Caluza v. Brown, 7 Vet. App. 498 (1995).  

As part of the current VA disability compensation claims, in recent statements, the Veteran has asserted that her symptoms of a bilateral wrist disability and an eye disability have been continuous since service.  She asserts that she continued to experience symptoms relating to the wrists (pain and carpal tunnel syndrome) and the eyes (decreased visual acuity) after she was discharged from service.  In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of either of these disabilities after service separation.  Further, the Board concludes that her assertion of continued symptomatology since active service, while competent, is not credible.  

The Board finds that the Veteran's more recently-reported history of continued symptoms of a bilateral wrist disability and an eye disability since active service is inconsistent with the other lay and medical evidence of record.  Indeed, while she now asserts that her disorders began in service, in the more contemporaneous medical history she gave at the service separation examination in December 2004, she denied any relevant history or complaints of symptoms .  Specifically, the service separation examination report reflects that the Veteran was examined and her eyes were found to be normal clinically.  Although bilateral wrist pain was noted on clinical evaluation in December 2004, there was no bilateral wrist pathology present to render a diagnosis on VA examination in June 2005, approximately 1 month prior to the Veteran's service separation in July 2005.  Her in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation.  See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later).  

The post-service medical evidence does not reflect complaints or treatment related to an eye disability at any time following active service.  And, as noted elsewhere, the Veteran's myopia noted on VA examination in June 2005 is considered a congenital defect for which service connection is not available.  See 38 C.F.R. § 4.9 (2012).  The Veteran did not claim that symptoms of her disorders began in (or soon after) service until she filed her current VA disability compensation claim.  Such statements made for VA disability compensation purposes are of lesser probative value than her previous more contemporaneous in-service histories.  See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements).   These inconsistencies in the record also weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service.  See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service).  

The Board has weighed the Veteran's statements as to continuity of symptomatology and finds her current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than her previous more contemporaneous in-service history and findings at service separation and the absence of complaints or treatment for years after service.  For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation.


ORDER

Entitlement to an initial rating greater than 10 percent prior to October 30, 2007, and greater than 30 percent thereafter, for bronchial asthma is denied.

Entitlement to an initial rating greater than 10 percent prior to January 30, 2012, and greater than 20 percent thereafter, for a lumbosacral spine disability is denied.

Entitlement to an initial compensable rating prior to July 10, 2006, and greater than 10 percent thereafter, for sinusitis is denied.

Entitlement to service connection for a bilateral wrist disability, to include as due to an undiagnosed illness, is denied.

Entitlement to service connection for an eye disability, to include as due to an undiagnosed illness, is denied.



____________________________________________
WAYNE M. BRAEUER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs