Citation Nr: 1321297 Decision Date: 07/02/13 Archive Date: 07/12/13 DOCKET NO. 09-16 641 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active military duty from June 1976 to June 1980. The appeal comes before the Board of Veterans' Appeals (Board) from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Board remanded the claim in January 2012 for additional development, and it now returns to the Board for further review. The issue of entitlement to service connection for bilateral knee disorders including as secondary to service-connected low back disability is has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Veteran informally raised this issue in a May 2013 submission. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran is currently assigned a 40 percent disability rating for low back disability. The low back disability is his only service-connected disability. 2. The Veteran's service-connected disability does not render him unable to secure and follow a substantially gainful occupation. CONCLUSION OF LAW The criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist Veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his/her representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the Veteran that, to substantiate a claim, the Veteran must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from non-compensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative Diagnostic Codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores, 580 F.3d 1270. A TDIU claim is a particular type of increased rating claim. The Court has held that entitlement to a TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). The present claim originated with the Veteran's claim for an increased rating for his service-connected low back disability. In its January 2012 decision, the Board determined that the notice and duty to assist requirements with regard to the increased rating claim for the low back disability were satisfied. The Board now finds that these requirements were also satisfied with regard to the claim for TDIU. A predecisional letter dated September 2005 fulfilled duty to notify requirements with regard to the TDIU claim. Subsequent letters in July 2006, May 2007, and December 2008 additionally addressed notice with regard to increased rating and effective date elements. The Board finds that with regard to any late notification that may be applicable to the TDIU claim, there was no prejudice to the Veteran because the Veteran has been given additional time to submit evidence and argument and the matter was readjudicated. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The duty to notify has been satisfied. The Board also finds that VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The medical records associated with the Veteran's claim for disability benefits through the Social Security Administration (SSA) have also been associated with the claims file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. With respect to increased rating claims, including claims for TDIU, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2011). As discussed below, the Veteran was afforded VA examinations in February 2006 and September 2009 for his lumbar spine disability, and he was afforded additional examinations in February 2012 specifically addressing questions of unemployability due to the Veteran's service-connected spine disability. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that "once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one"). The VA examinations, taken as a whole, are adequate, as they were predicated on a review of medical records, and the examiners fully addressed the criteria that are relevant to the TDIU at issue here. Thus, there is adequate medical evidence of record to make a determination in this case. There is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected lumbar spine disability since he was last examined by VA in February 2012. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4) (2012). The Board also finds that all development required by the Board's January 2012 remand was substantially completed. This included obtaining a VA examination addressing medical issues pertinent to the TDIU claim, followed by RO readjudication of the claim with issuance of a supplemental statement of the case (SSOC) prior to return of the case to the Board for further review. Only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97 (2008). A submission by the Veteran in May 2013 is, with respect to the TDIU claim, merely duplicative of prior assertions, and hence does not require additional RO review of the claim prior to the Board's decision on the TDIU claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. Newhouse v. Nicholson, 497 F.3d 1298 (2007). II. Claim for TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Under section 4.16(b) of VA regulations, when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), the RO may submit such case to the Director, Compensation and Pension (C&P) Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). The Board is precluded from granting a total rating under section 4.16(b) because the authority to grant such a rating is vested specifically in the Director, C&P Service. Should the Board find that a case it is reviewing on appeal is worthy of consideration under section 4.16(b), the Board may remand the case to the RO for referral to the Director, C&P Service, but the Board may not grant a total rating in the first instance. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996) (noting that Board may consider whether referral to "appropriate first-line officials" for extra-schedular rating is required); see also Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Thus, the decision by the RO whether to refer a case to the Director for extra-schedular consideration is an adjudicative decision subject to review by the Board. Moreover, where there has been a review by the C&P Director, that determination is subject to review by the Board on appeal. Anderson v. Shinseki, 22 Vet. App. 423, 277-28 (2009) (noting that "although the Board is precluded from initially assigning an extraschedular rating, there is no restriction on the Board's ability to review the denial of an extraschedular rating on appeal."). In determining whether a claimant is unable to secure or follow a substantially gainful occupation, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when the Board conducts a TDIU analysis, it must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Beaty v. Brown, 6 Vet. App. 532, 534 (1994) (considering veteran's eighth grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356, 357 (1991) (considering veteran's master's degree in education and his part-time work as a tutor). That a veteran can no longer perform a particular job, however, is not dispositive of the issue. Rather, the criteria for a TDIU rating contemplate that a veteran's service-connected disabilities alone preclude him from securing or following all forms of substantially gainful employment. For a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor which takes the case outside the norm. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran's sole service-connected disability is a low back disability currently evaluated under criteria in the VA Schedule for Rating Disabilities as 40 percent disabling. Therefore, the percentage requirements for consideration of his claim under section 4.16(a) have not been met, and the Board must consider whether this appeal warrants further extra-schedular consideration by the Director, C&P Service, under section 4.16(b). With regard to the latter, the Board notes that the RO already referred this case to the C&P Director, and his Memorandum, dated in March 2013, is in the claims file. In applying for a TDIU rating, the Veteran contends, in effect, that his service-connected low back disability renders him "unable to secure and follow a substantially gainful occupation." 38 C.F.R. § 4.16(b). In this case, the record reflects that the Veteran performed work as a dentist in service and that he worked his entire life following service as a dentist until 2006. In a submission in support of his claim dated in November 2005, the Veteran stated: Ever since I injured my back in the Navy in 1977 or 1978 I have had episodes of varying degrees of pain and immobility. Recently it has reached a point where some mornings I cannot put on my shoes until I have been up for a while[,] and at the end of the day I have difficulty moving and bending. To cope I have had to cut back on the number of hours and number of days I work. Lay statements, including those from his dental assistant and his fiancé, and a February 2006 VA Spine examination report support the Veteran's description of ongoing work as a dentist with difficulty due to lumbar symptomatology. The February 2006 examiner characterized the condition as lumbar degenerative disk disease with back motion reduced by half and ongoing back pain, treated daily with Motrin. A July 2005 private record from a pain management facility reflects that the Veteran complained of stabbing and aching pain of the lumbar spine, left buttocks, and the left genital area. He asserted that the pain was aggravated with climbing stairs and arising from a seated position, and that it was relieved with stretching. Upon examination, the physician found no gross limitation of motion; normal strength, sensation, and gait; and no pain to palpation of the lumbar spine. The diagnoses were "degen[eration] of lumbar or lumbosacral intervertebral disc" and lumbosacral spondylosis without myelopathy, and the doctor administered an epidural steroid injection. The Veteran underwent repeated steroidal injections, and follow-up records reflect some pain improvement following these injections. An August 2005 letter from a private neurologist reflects that the Veteran complained of difficulties including generalized fatigue, excessive daytime drowsiness, difficulty sleeping, lower extremity pain particularly in the left buttock, back pain, intermittent headaches, and numbness in the proximal anterior thigh. That examiner noted that MRIs of the left hip and thyroid testing were unremarkable, whereas lumbar MRIs showed mild to moderate degeneration with some spinal canal and neural foraminal narrowing. The examiner also suspected that the Veteran's fatigue might be related to a sleep disorder. The Veteran underwent an August 2005 sleep study, with findings including "moderate, predominantly obstructive sleep apnea." In a March 2006 letter, the Veteran clarified that he only worked three days per week in his dental practice rather than five due to back soreness. He added that he planned to sell his practice and discontinue dentistry soon. He also added that he formerly exercised every other day but now did so only once per month due to his back soreness. In a May 2006 letter, the Veteran stated that his lower back pain was worsening, with two additional cortisone injections in April 2006 providing no relief. He added that his physician told him that his back could not tolerate additional injections. The Veteran reported that he was taking Motrin during the day, Flexeril at night, and wearing lidocaine patches on his back for 12 hours daily. He added that he had further cut back on his work, working six hours per day three days per week instead of eight to ten hours per day five days per week, and that by mid-day on his work days, his back prevented him from bending over patients or sitting down or getting up without pain. He stated that he also had taken more days off work. Medical reports and other evidence from the Social Security Administration (SSA), reflect that, in September 2006, the Veteran suffered an ischemic optic neuropathy resulting in 75 percent vision loss (left eye blindness with no light perception and lower half of right eye visual field loss as well as a substantial portion of the central visual field in the right eye) following an aortic root repair and that he ceased practicing dentistry following that ischemic optic neuropathy. In a November 2006 letter, a private rheumatologist noted that the Veteran had been seen first in 2005 and most recently in May 2006 for chronic back pain. The rheumatologist stated that the Veteran had an epidural which provided little help due to the nature of the Veteran's work as a dentist, and then noted that the Veteran was unable to work due to pain which made him "unable to sit, stand, walk, or carry objects for very long," as well as due to medication which caused him to be "very hung over and cause memory loss." The doctor added that the Veteran required fine motor movements for his work as a dentist but also noted in the letter that she was not able to perform an examination addressing the Veteran's degree of disability: "Unfortunately, I am not a disability physician and would be unable to do the appropriate examination." The rheumatologist did note that while an EMG/NCV was normal, an MRI revealed both moderate lumbar stenosis and degenerative disk disease, with spinal canal narrowing at L2/L3. A post-vascular-surgery follow-up treatment note from October 2006 reflected the persistence of the visual field impairments but with the Veteran engaging in moderate exercise, including walking approximately a mile each day and ascending stairs, though becoming somewhat out of breath ascending stairs. The Veteran did not then complain of impairment due to his low back, but rather reported that he had not returned to work due to his vision problems. An additional post-surgical follow-up note later in October 2006 showed that the Veteran was performing mild exercise, and thus progressing from a cardiovascular standpoint. Again, lumbar difficulties were not noted. SSA records reflect that the Veteran was awarded SSA disability benefits primarily based on the non-service-connected ischemic optic neuropathy resulting in 75 percent vision loss. An SSA medical consultation examination in January 2007 determined that the Veteran could sit and stand for six hours of an eight-hour workday and could frequently lift ten pounds and occasionally lift twenty-five. The examiner also found no postural limitation except for climbing ladders, and no physical manipulation limitations. The examiner noted the Veteran's marked visual field impairment, with no light perception in the left eye and vision in only the upper half of the visual field in the right eye as well as a small portion of the central visual field on the right. The examiner concluded that this limited the Veteran's ability to look down, read, and perform binocular activities. The visual impairments were noted to be of ischemic origin, from an aortic root repair in September 2006, with no expectation of improvement. The examiner also noted that the Veteran had lumbar spondylosis and degenerative disk disease with continuing back pain treated with epidurals but without motor or sensory impairment. Upon a January 2007 internist examination of the Veteran's lumbar spine condition for SSA purposes, the examiner noted that the Veteran complained of worsening back pain, inability to bend over, especially in the morning, and inability to bend over his patients in his practice as a dentist. However, the internist found upon examination that the Veteran could bend fully, climb onto the examination table, arise from a reclining position, and walk unassisted. The examiner found that the Veteran had no difficulty with standing, sitting, bending, walking, lifting, or handling objects. The examiner assessed a normal neurological examination. In a letter from the Veteran contained within the Social Security records, the Veteran protested that the examination of his spine conducted in January 2007 was rushed and incomplete. In an May 2009 VA Form 9, the Veteran contended that, although he did have a visual handicap, his reason for not working currently was "primarily" due to his degenerative low back condition. The Veteran went on to assert that because his orthopedic surgeon suggested that he attempt to work, he tried working but found that he "developed back pain and immobility immediately." The orthopedic surgeon the Veteran referenced in his May 2009 VA Form 9 wrote an opinion letter dated in April 2009. This letter begins with the assertion, "[The Veteran] is currently working as a dentist." The letter goes on to state that the Veteran requested a letter to address his incapacity for employment due to his low back disorder. In the letter, the surgeon, M.Q., notes the presence of degenerative changes to the Veteran's lower spine, but first concludes that the Veteran should attempt work because this would do him no harm, from a low back perspective, even though it might cause some pain. However, M.Q. also notes another examiner's medical opinion that the Veteran was unable to practice dentistry due to his "bilateral optic neuropathy with irreversible visual field loss." M.Q. provided an addendum two weeks subsequent to his April 2009 opinion letter, as follows: "I had a conversation with [the Veteran] 4/30/2009. He indicates that he has tried to work as a dentist and feels that his recurrent back pain precludes this on a permanent basis. My understanding is that he has made a decision to terminate the practice of dentistry and sell his practice due to chronic and recurrent lower back pain symptoms." Upon a VA examination for compensation purposes in September 2009 addressing the Veteran's low back, the Veteran indicated that his pain levels were between 2 and 6 on a scale of 1 to 10. The Veteran denied any radiation of pain but indicated right groin numbness with no pain anteriorly, and he reported that flare-ups occurred about once a week and last about one day. He took pain medication. The Veteran noted an inability to lift objects or do yard work. He also indicated that his ambulatory distance was about three blocks before he needed to sit down. The examiner noted that the Veteran's ambulation was slow with a cane, with an even heel to toe gait. Upon objective examination, the September 2009 examiner found full lower extremity strength, with the lower extremities neurologically intact. There was some limitation of motion with pain at ends of ranges but no weakness or incoordination and only mild lack of endurance. The examiner noted that three years prior to the examination the Veteran had an ischemic optic neuropathy and lost 75 percent of his vision which precluded him from working as a dentist. The examiner also observed that the Veteran's demonstrated slow gate sped up when unobserved. The Veteran was afforded two VA examinations in February 2012. In the first, the Veteran reported progressive low back pain since service, with use of a TENS unit and pain in the left lower back, buttock, and groin. The Veteran also reported having a deep burning pain in the left buttock, back, and groin during flare-ups, during which times he reported that he could not function. The first examiner noted that while the Veteran had some limitation of motion of the low back, the examiner found no objective evidence of painful motion and found no additional limitation of motion with repetitive movement. The examiner did conclude that the Veteran had some pain with low back movement as well as limitation of motion and some disturbance of locomotion but did not conclude that this precluded all gainful activity. Rather, the examiner assessed that the Veteran was capable of unlimited seated activity, though he was limited to 20 minutes of standing activity and to 10 pounds lifting as part of work activities. At the second February 2012 VA examination, the examiner noted that the Veteran had a private dental practice beginning in 1980 up until "2008" (sic) and that he suffered a post-operative optic ischemic neuropathy following which he ceased practicing dentistry. The Veteran asserted at the examination that he used a wheelchair due to his back disability. The examiner opined that the Veteran was precluded from continuing practice as a dentist or seeking work as a dentist due to his lumbar stenosis and back pain, due to impairment of "going from sitting to standing to examine the patient, twisting to examine the patient, etc." However, the second February 2012 examiner did not address the Veteran's capacity to perform other gainful work. Thus, the second examiner's conclusions are not in conflict with those of the first February 2012 examiner, that the Veteran is not precluded from sedentary work due to his service-connected low back disorder. Pursuant to 38 C.F.R. § 4.16(b), the case was referred to the Director, C&P Service, for TDIU extraschedular consideration in the first instance. The C&P Director found that the evidence showed that the Veteran was unable to work as a dentist but did not show that he was unable to perform any substantially gainful employment. The C&P Director found that the Veteran's service-connected low back disability caused moderate functional restrictions and would affect his ability to perform physically demanding work, but that the evidence did not show that he was unable to follow a substantially gainful occupation due to his lumbar spine condition. The Board agrees with the C&P Director. The Board concludes that the Veteran's service-connected low back disability does not prevent the Veteran from securing and following a substantially gainful occupation. 38 C.F.R. § 4.16(b). In this regard, the Board has considered the Veteran's contentions of back pain precluding work, particularly work as a dentist, but finds that, although his service-connected back condition might prevent him from working as a dentist, the evidence of record does not show that his back condition renders him unable to secure and follow all substantially gainful occupations. Rather, the record of treatment and examination reports over the claim period affords a consistent medical picture of some limitation of motion and some pain due to the low back disorder but not impairment for all forms of work including sedentary work. The findings of January 2007 SSA disability evaluation addressing the low back disability reflected substantial low back functional capacity (ability to bend fully, climb onto the examination table, arise from a reclining position, and walk unassisted), and these findings support the conclusion that, although the Veteran may be precluded from the more demanding tasks of stooping over patients all day as dentist, he would not be precluded from less physically demanding tasks by his low back disability. In the April 2009 letter from M.Q., the surgeon did not find any harm in the Veteran attempting work notwithstanding his low back disorder, and did not anticipate much more symptomatology than the Veteran experiencing some pain as a result of the low back disorder. This is consistent with the overall weight of the medical evidence, to the effect that the Veteran's low back disorder results in some limitations of motion and some pain with motion, but does not preclude work not requiring significant mobility. This picture of some, but not total, disability resulting from the back condition, continues to be reflected by the most recent VA examinations in February 2012, which also do not show an inability to perform sedentary work: the first February 2012 examiner explicitly finding no such inability, and the second finding only preclusion from the practice of dentistry because of its particular demands including standing and twisting to examine patients. The Board concedes that the Veteran's low back disorder with associated pain and limitation of motion likely precludes him from returning to the practice of dentistry. However, the weight of medical evidence is against the Veteran being unable to secure or follow an occupation requiring less physically demanding work and some forms of sedentary work. Although the November 2006 letter by a private neurologist was to the effect that virtually any prolonged activity would be precluded by the Veteran's low back disorder, the Board finds that that portion of the November 2006 letter was history provided to the neurologist by the Veteran which is outweighed by evidence showing consistent and objective findings of capacity for prolonged sitting for work activities. Similarly, the Board finds the Veteran's assertion in May 2009 that he attempted to work but suffered "immobility immediately" not persuasive for several reasons. First, the Veteran did not state what work he attempted, but if this was dental work, the record already establishes that Veteran's is no longer able to practice dentistry. Second, if the unspecified work the Veteran attempted which resulted in low back pain and immobility was physically demanding work, this would be unsupportive of his TDIU claim because his back disability does limit physically demanding work such as dentistry but has not been shown by the evidence to prevent him from engaging in all types of work. Third, if the unspecified attempted work were of a sedentary nature, there is no medical support in the record for a sedentary activity to have resulted in "immediate immobility" associated with the Veteran's low back disability, as the Veteran has alleged. Thus, although the Veteran's description of the pain he experiences as a result of his low back disability is competent evidence, the Board finds his statements about the degree of impairment caused by the pain not credible because they are inconsistent with more objective findings of medical examiners about the degree of functional impairment resulting from his low back disability. Concerning the credibility of the evidence, the Board notes that "definitions of credibility do not necessarily confine that concept to the narrow peg of truthfulness. It has been termed as 'the quality or power of inspiring belief. . . .' Credibility . . . apprehends the over-all evaluation of testimony in the light of its rationality or internal consistency and the manner in which it hangs together with other evidence." Indiana Metal Prods. v. NLRB, 442 F.2d 46, 51-52 (7th Cir. 1971) (citations omitted); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (citing Indiana Metal Prods., 442 F.2d at 52). In this case, the Veteran's statements about the degree of impairment resulting from his low back disability do not "hang[] together" in a consistent manner with the other evidence of record, particularly medical reports showing only moderate limitation of his physical functional capacity, and that inconsistency renders his statements less believable and convincing than the other evidence. In addition to the medical reports of record, the Board also finds persuasive in this regard the SSA conclusion that the primary and secondary diagnoses which rendered the Veteran unable to work in accordance with that agency's regulations were an aneurysm repair with cardiac arrest and the ischemic injury to the optic nerve. Lumbar disc disease was noted on the Physical Residual Functional Capacity Assessment from SSA only under "Other Alleged Impairment." Similarly, SSA examination findings from January 2007 showing the capacity for prolonged physical activity such as sitting and standing for six hours of a work day also constitute persuasive evidence of the Veteran's ability to engage in physical activity such that he would not be prevented from securing and following all forms of substantially gainful employment. In addition, the Board also finds that the Veteran's level of educational attainment, including both college and an advanced degree in dentistry, would allow the Veteran to obtain and retain substantially gainful sedentary work. With regard to the latter, the Board notes that, as reflected in the second February 2012 VA examination report, the Veteran has an undergraduate degree in chemistry, a dental degree, and extensive knowledge and experience in the field of dentistry. This would most likely qualify him for some forms of substantially gainful work not requiring the physical demands of dentistry, such as medical insurance or dental claims work or other similar sedentary fields where his education and experience could prove useful. For the reasons noted above, the Board finds that the preponderance of the evidence is against the claim that the Veteran is unable to secure and follow a substantially gainful occupation by reason of his service-connected low back disability. Accordingly, TDIU is not warranted. 38 C.F.R. § 4.16(b). ORDER Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs