Citation Nr: 1324241 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 03-08 018 ) DATE ) MERGED APPEAL ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for a disability manifested by symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel. 2. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability manifested by symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel. 3. Entitlement to service connection for a chronic cardiovascular disorder to include coronary artery disease and myocardial infarction residuals. 4. Entitlement to an initial disability evaluation in excess of 40 percent for lumbar spine degenerative disc disease. 5. Entitlement to an initial disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 6. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU rating). 7. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or at the housebound rate. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The Veteran had active service from December 1971 to May 1978, as pointed out by the Veteran and documented by service department records. The issues remaining on appeal come before the Board of Veterans' Appeals (Board) on appeal from regional office (RO) rating decisions beginning with a February 2005 rating decision that granted service connection for degenerative disc disease of the lumbar spine, and assigned a 40 percent rating effective August 15, 2003; the assigned rating remains on appeal. The issues of entitlement to service connection for spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel; a TDIU rating; and special monthly compensation based on the need for regular aid and attendance or at the housebound rate, were denied in a September 2005 rating decision. Entitlement to service connection for coronary artery disease and myocardial infarction residuals was denied in a September 2006 rating decision, and in June 2011, the RO granted service connection for PTSD, effective October 13, 2004; the Veteran appeals the assigned 50 percent evaluation for that disability. In August 2009, the Veteran and his wife appeared at a videoconference hearing held before a Veterans Law Judge who is no longer with the Board. At that time, the issue of entitlement to compensation under 38 U.S.C.A. § 1151 was raised, and subsequently incorporated into the appeal. The case was previously remanded in November 2009 and February 2012. In May 2013, the Veteran declined an opportunity to appear at another Board hearing. The issues of service connection for a cardiovascular disorder, an initial disability evaluation in excess of 50 percent for PTSD, and entitlement to SMC based on the need for regular aid and attendance or at the housebound rate are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDINGS OF FACT 1. Currently shown adrenomyeloneuropathy, manifested by symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel, at least as likely as not had its onset during active military service. 2. The grant of entitlement to service connection for adrenomyeloneuropathy renders moot the claim for compensation, under the provisions of 38 U.S.C.A. § 1151, for chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel. 3. Since the effective date of service connection, lumbar spine degenerative disc disease has been manifested by limitation of motion, without ankylosis, incapacitating episodes lasting 6 weeks or more per year, or objective manifestations of sciatic nerve impairment. 4. Exclusive of the grant of service connection for adrenomyeloneuropathy in this decision, service connection is currently in effect for posttraumatic stress disorder (PTSD), assigned a 50 percent rating; lumbar spine degenerative disc disease, assigned a 40 percent rating; residuals of cold injury to the feet, assigned a 20 percent rating for each foot; tinnitus, assigned a 10 percent rating; and noncompensably rated bilateral hearing loss. His combined disability rating is 80 percent. 5. The Veteran's service-connected disabilities, including adrenomyelo-neuropathy, preclude gainful employment. CONCLUSIONS OF LAW 1. Adrenomyeloneuropathy, manifested by symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel, was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The Veteran's claim for VA benefits under the provisions of 38 U.S.C.A. § 1151 is moot. 38 U.S.C.A. §§ 1110, 1131, 1151 (West 2002); 38 C.F.R. § 20.101 (2012). 3. The criteria for an evaluation in excess of 40 percent for lumbar strain degenerative disc disease have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45 (2012), § 4.71a, Diagnostic Code 5295 (2002 and 2003), 5235-5243 (2012). 4. The criteria for a TDIU rating are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist a claimant in substantiating a claim for VA benefits. U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); see 38 C.F.R. § 3.159 (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Id.; see Quartuccio v. Principi, 16 Vet. App. 183 (2002). In this decision, the Board grants the claims for service connection adrenomyeloneuropathy, and a TDIU rating, which constitutes a complete grant of those benefits sought on appeal. Moreover, the grant of service connection for adrenomyeloneuropathy renders the 38 U.S.C.A. § 1151 claim moot. A discussion of VA's duty to notify and assist is unnecessary as to those issues. Concerning the issue of entitlement to a higher rating for lumbar spine degenerative disc disease, the Veteran's appeal arises from his disagreement with the initial evaluation following the grant of service connection. 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). Nevertheless, in letters dated in February 2008 and May 2008, the RO advised the claimant of information necessary to substantiate the claim. He was advised of various types of lay, medical, and employment evidence that could substantiate his claim, and of his and VA's respective obligations in obtaining such evidence. The Veteran was also provided with information regarding effective dates. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). This duty includes assistance in the procurement of service treatment records and other pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records have been obtained, as have VA treatment records. Private treatment records adequately identified by the Veteran have also been obtained. Records were requested from Social Security Administration (SSA), but that agency responded, in August 2012, that there were no SSA records available. VA examinations were provided in January 2005, February 2005 May 2006, August 2010, and October 2012; those examinations, in conjunction with the other evidence of record, describe the disability in sufficient detail for the Board to make an informed decision. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Pursuant to the November 2009 Board remand, the Veteran was provided notice of the requirements for establishing entitlement to a higher evaluation on an extraschedular basis. In addition, he was afforded an examination for his spine. The remainder of the remand instructions pertained to other issues. Therefore, the Board finds that the remand terms have been substantially complied with. McBurney v. Shinseki, 23 Vet. App. 136, 140 (2009) (remand terms must be complied with, unless an explanation is provided as to why the terms will not be fulfilled); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (the veteran is entitled to substantial compliance with the Board's remand directives). The Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service connection for Adrenomyeloneuropathy Service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted on a presumptive basis for certain chronic diseases, such as organic diseases of the nervous system, if manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1110, 1112(a)(1), 1113, 1131, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection, the evidence must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the current disability and the in-service disease or injury (or in-service aggravation). Holton v. Shinseki, 557 F.3d 1362, 1355 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service treatment records show that in February 1973, the Veteran was seen with possible frostbite to both feet, having recently returned from Germany. He said his feet had gotten cold in January, and that he had first noted numbness and tingling about a week later. He had some pain and felt his feet were swollen, although there was no evidence of edema on examination. There was pain on palpation of the balls of the feet and toes, and the impression was minimal cold injury. He also complained of back pain, with no cause found, beginning in March 1976. At that time, he reported that back pain had been present for two months. He had muscle spasms with full range of motion and without radiation. In April 1976, he attributed the onset to a lumbar puncture in 1974. In March 1977, he reported that he had originally injured his back about a year earlier doing heavy lifting. On examination, he had slightly visible scoliosis, and tenderness from T-12 to L1 or 2. X-rays of the back during service were normal. On the medical history reported on the January 1978 separation examination, the Veteran responded "yes" to a question of whether he had now, or had ever had, "leg cramps." He also reported recurrent back pain. The first post-service medical record is a January 1998 initial health history obtained when the Veteran was first seen for treatment at a VA facility. He reported a medical history of a right total knee replacement in 1988 after a motor vehicle accident. He ambulated using a cane. He complained of fatigue, tiredness, and nocturia 8-20 times. He said his legs would become numb and give out on him. He had chronic indigestion. He had trouble maintaining an erection. He stated that his genitourinary problems had been going on for "years," and he "just didn't come in any sooner." X-rays showed evidence of a prior fracture of the knee, but there was no evidence of any arthroplasty. On a VA examination in October 1998, the Veteran complained of incontinence on and off for 20 years. He complained of severe knee pain, and he said he used a cane for ambulation. His wife said that when he walked around the house, he would use the walls for support. Normally, he walked with a cane, but on examination, normal heel to toe roll was absent; he walked primarily on the balls of his feet or his toes in a scissors gait. In November 1998, he was referred for a neurology consult, for a more than one year history of increasing gait disturbance, recently increasing bowel incontinence, and possible neurogenic bladder. In addition, he had been found to be hyperreflexive in both lower extremities, and had around 8-10 beats of clonus, as well as a positive Babinski test. He also seemed to have loss of fine touch and vibratory sensation to at least the umbilicus. He was scheduled for an MRI. On the November 1998 neurology evaluation, he reported gait disturbance and urinary incontinence. He reported lower urinary tract symptoms since early 1980, gradually worsening over the years. He started to lose bladder control two weeks earlier, but it had been determined that he did not have any prostate problems. On examination, there was slightly decreased finger rubbing bilaterally. He did not have any dysarthria. Sensation was decreased to light touch on both lower extremities. It was decreased to pin prick bilaterally at levels around T11-L1. He had increased muscle tone in the lower extremities. Strength was normal. Hoffman's was positive bilaterally, and he had bilateral ankle clonus. Gait was not assessed because he was unable to walk. The impression was T11 level cord compression, and the etiology was probably degenerative spinal disease. Other possible causes were epidural abscess, Pott's disease, primary or metastatic tumor around the spinal canal, and primary cord lesion. On a spinal cord injury (SCI) evaluation in November 1998, the Veteran complained of a burning sensation on the bottom of his feet. He had increased tone and rigidity in both lower extremities and pelvis. Range of motion was normal. The examiner described an abnormal gait, including dragging the toes during the initial swing. He was very stiff and unable to attain full range of motion when ambulating. On a December 1, 1998, psychology assessment, the Veteran reported that after his discharge from service, he worked as a machinist. He was employed full time for the most part until 1990, when he began experiencing pain in his feet and legs that precluded him from working full time. He said that he never sought medical treatment for these complaints until last year, despite their impact on his functioning. He worked at odd jobs intermittently until last year. Within the last month, he reported that he had lost feeling in both legs, was retaining fluid and had lost bladder control. The Veteran was hospitalized in a VA facility in December 1998 for treatment of a urinary tract infection. He was noted to have level T11 spastic paraplegia, date of injury, 1980; method of injury, unknown. The list of final diagnoses included urinary tract infection, T11 spastic paraplegia, and "urogenic" bladder. The Veteran was again hospitalized in a VA facility in January 1999, for acute dehydration. At that time, his history was "T11 paraplegia, secondary to flu shot x3 months. . ." This is the first mention of a flu shot as associated with the onset of symptoms. At a Board videoconference hearing in August 2009, the Veteran reported injuring his back during service. He was asked about a December 2002 record in which he stated his paraplegia followed a spinal tap and treatment for meningitis in service. The Veteran said that he remembered them sticking something into his back in the military in his early years, which hurt the back "real bad," but they never told him why or what was found. VA records show that for many years, the Veteran has been followed in an SCI clinic. As noted on a VA examination in August 2010, the history regarding the Veteran's back is confusing. In April 1976, he reported back pain since a lumbar puncture in 1974. In January 1977, he reported the onset had been a lifting injury. In January 1978, he denied back pain. On December 1, 1998, he said he had lost feeling in his legs and lost bladder control a month earlier. On December 12, 1998, he said he had had spastic paraplegia since 1980. On December 4, 2002, he stated he had had an incomplete paraplegia since a lumbar puncture in 1972. On December 5, 2002, he stated that before a flu shot in 1997, he had bowel and bladder symptoms, and that his right leg had been giving out. The VA examiner in August 2010 concluded that the Veteran's paraplegia and neurogenic bladder were coming from a spinal cord disorder, and that, despite the confusing history, it could be said that the flu shot in 1997 did not cause the spastic paraplegia, because he had already had symptoms "for years." SCI clinic records show that in February 2011, the Veteran said that he had injured his back in service, with mid/low back pain. He became ill, and was hospitalized for 2 months. Toward the end of 1971, he had increasing thoracic/lumbar pain, and had a very painful lumbar puncture. He had chronic pain in his back after that, and by 1992 he was walking with a cane, and started self catheterizing around that time. Reportedly, around 1997 he received a flu shot and became acutely ill and was hospitalized at the VA, at which time he was found to have a neurogenic bladder and bowel and spastic T11 paraplegia with negative work-up with MRIs, confirmed by November 1998 and December 1998 discharge summaries. He had been wheelchair bound ever since. The physician noted that, however, the etiology was very unclear. MRI scanning of the entire spine had been essentially negative for underlying spinal cord pathology. The Veteran was referred for a neurology consult in April 2011, to determine the etiology for paraplegia. He was noted to have had a back injury in 1970. He stated that his back pain started secondary to injury during service, which progressively worsened since 1977. He developed bladder incontinence in 1978. He needed a cane to walk beginning in 1992, and had developed paraplegia in 1997 after a flu vaccine. He had not worked since 1990. On examination, strength in the lower extremities ranged from 1/5 to 2/5. He had increased tone in both lower extremities. There was loss of sensation below the knees in both legs. The recent MRI images did not reveal changes which explained his chronic myelopathic picture. There was no cord atrophy or expansion. Examination showed spastic paraparesis. The impression was chronic paraplegia, cause unclear. Several differential diagnoses were listed, and among the tests conducted to identify the cause was a very long chain (VLC) fatty acid test which revealed an elevated C:26 level. The neurologist noted that the history of slowly progressive myelopathy over "decades," together with that test, were consistent with a diagnosis of adrenomyeloneuropathy, but it was recommended that the VLC fatty acid assay be repeated, and the serum AM cortisol level checked, to see if he had adrenal insufficiency typically present in adrenomyeloneuropathy. He was referred for an outside neurology evaluation. The doctor explained that this was needed because the disease was rare and not many physicians had expertise. Meanwhile, a VA opinion was obtained in October 2012, in connection with his appeal. The author said that a February 2011 lumbar MRI report specifically stated there was no reason identified to explain the paraplegia. Since then, an EMG/NCV performed in May 2012 had shown peripheral polyneuropathy with demyelinating features, which indicated central nervous system changes that had nothing to do with degenerative disc disease. Recent medical evidence showed he was being worked up for adrenomyeloneuropathy, which was a rare genetic disorder that caused progressive central nervous system disease, and was completely different from degenerative disc disease. There was no evidence to suggest any role of lumbar degenerative disc disease in aggravating his progressive central nervous system genetic disease. After outside neurological work-up, S. Youssof, M.D., observed that since the Veteran's last visit in June 2012, genetic testing of the ABCD-1 gene had confirmed the diagnosis of adrenomyeloneuropathy. His complaints included constipation, urinary incontinence, and generalized musculoskeletal pain. He had moderately increased tone in the upper extremities, and severely increased tone in the lower extremities. He was unable to ambulate unassisted. The impression was that he had adrenomyeloneuropathy with symptoms that began at roughly the age of 23 or 24 while in the military. The doctor noted that he developed back problems at that time, and that he developed urinary incontinence and constipation around the same time, in his early 20s. The symptoms had progressed over the years, and in his 30's he began to use a cane. In 1998 after getting a flu shot, he became seriously ill, was paralyzed, and has had severe paraplegia of the lower extremities since then. He had been self-catheterizing his bladder since 1995, and also had numbness going up to both hips prior to 1998. The Veteran's treating physician at the VA SCI unit wrote, in January 2013, that the Veteran's history was that he was healthy when he entered military service. He then developed neurologic symptoms when he was in the military that over the years resulted in paralysis of his legs as well as a neurogenic bladder and generalized weakness. The exact cause of his neurologic dysfunction over the years had been unclear until recently when Dr. Youssof diagnosed him as having adrenomyeloneuropathy, which was the obvious cause of his neuromuscular disease. He was wheelchair bound and totally disabled. The physician stated that based on the Veteran's history, he developed his disease when he was in the military. The Veteran was hospitalized in a VA medical center (VAMC) from March to April 2013. His discharge diagnoses/medical problems were noted to be adrenomyeloneuropathy with paraplegia, dysarthria, dysphagia, neurogenic bladder, and urine infection. He was discharged to home hospice care. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Daye v. Nicholson, 20 Vet. App. 512 (2006). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). During the past couple of years, the Veteran's symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel have been diagnosed as a rare neurological condition, adrenomyelo-neuropathy. Since then, both the private neurologist who diagnosed the condition and the Veteran's VA treating the physician have attributed the onset to symptoms shown in service. The Board notes that, as can be seen above, the histories provided by the Veteran have not always been consistent, but symptoms of back pain of unknown etiology was shown in service, and, although no urinary problems were noted in the service treatment records, his statements as to the onset of urinary problems have for the most part related the onset to service or shortly thereafter. The Board also notes that the August 2010 VA examiner stated that by 1997, he had already had symptoms "for years." Because the evidence attributing the onset to service is based in significant part on the Veteran's history, which, as noted above, has not always been consistent, the credibility of his statements must be addressed. First, after a thorough reading of the Veteran's statements over the years, it is clear that his inaccuracies are not intentional. The inaccuracies may be attributed, in some instances, to his lack of medical expertise. For example, he reported, on at least two separate occasions in 1998, that he had undergone a total knee replacement, when, in fact, he had sustained a fracture. He stated on several occasions that his symptoms began with a lumbar puncture, or "spinal tap," in service, and on one occasion, that he had had meningitis at the time, but he clarified at his hearing that all he really recalled was being stuck with something in the back in service, which was followed by pain. The Board attributes some of his other inaccuracies to a genuine desire on his part to find a cause for his baffling symptoms by relating them to another event he recalls as happening around the same time, such as a flu shot. The records over the years show the Veteran's frustration with the lack of a definitive diagnosis of his problems. Moreover, although he now feels that his symptoms of spastic paraplegia began with a flu shot, when first seen, in 1998, he already had symptoms of the spastic paraplegia, but did not report the flu shot. In January 1999, he reported the symptoms as having begun with a flu shot 3 months earlier, but not only did he fail to mention any such onset in the intervening evaluations in November and December 1998, but the symptoms were already present when he was first seen in January 1998. The weight of the evidence establishes that although his symptoms may have worsened at around 1997 or 1998, more subtle symptoms had already been present for many years. Finally, he is attempting to recall events which took place many years ago, and, thus, some minor inaccuracies, such as with dates, can be ascribed to the passage of time. There is also evidence which, if not directly supporting the Veteran's claim, is of such significance that it cannot be used against the claim. For example, there are the Veteran's numerous complaints of back pain in service, for which no etiology was identified. Although he has been granted service connection for a back disability, Dr. Youssef appears to relate the back pain to the adrenomyelo-neuropathy. The Board notes that no support was found for any of the other etiologies posited over the years. In particular, a T11 spinal abnormality was thought to be the cause of his lower extremity symptoms in 1998, but never confirmed, and an MRI as recently as December 2004 was unremarkable. Also, the unexplained history of "leg cramps" on the separation examination cannot be ignored. Credible evidence dates the onset of his bladder symptoms to service or very shortly thereafter. The VA physician concluded that he developed neurologic symptoms when he was in the military that over the years resulted in paralysis of his legs as well as a neurogenic bladder and generalized weakness. Dr. Youssef also related the onset to service. Moreover, there is no medical evidence which contradicts the conclusions set forth in the most recent opinions. The VA opinions stating that his condition was unrelated to a flu shot or to service-connected degenerative disc disease are of no probative value, given the more recently established diagnosis of adrenomyeloneuropathy, a disease of genetic origin. For that matter, the private opinions that the condition is secondary to service-connected degenerative disc disease are also without probative value, in light of the established etiology. In short, the Veteran has been found to have adrenomyeloneuropathy, and the only opinions addressing the question of service onset have found that the disease was initially manifested during service. The October 2012 VA opinion, which stated that recent medical evidence showed adrenomyeloneuropathy, a rare genetic disorder that caused progressive central nervous system disease, and was completely different from degenerative disc disease, did not address the question of whether adrenomyeloneuropathy itself was initially manifested in service. In this regard, service connection may be granted for congenital or hereditary diseases if initially manifested in or aggravated by service. VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990); VAOPGCPREC 67-90, 55 Fed. Reg. 43253 (1990). In particular, a hereditary disease does not always rebut the presumption of soundness, and, thus, diseases of hereditary origin can be incurred in service. VAOPGCPREC 67-90, 55 Fed. Reg. 43253 (1990). According to this opinion, such diseases "can be considered to be incurred in service if their symptomatology did not manifest itself until after entry on duty." Id. The opinion went on to explain that "Only when symptomatology and/or pathology exist can he or she be said to have developed the disease." Id. "In this context we use the term "pathology" in the sense of an active disease process, not just a mere predisposition to develop a disease, which process may or may not precede symptomatology." Id. In this case, there is no evidence that the disease was manifested prior to service. In sum, service treatment records show unexplained symptoms during service, such as leg cramps and recurrent back pain, for which no etiology was found. After service, the Veteran did not seek medical treatment for his developing neurological symptoms for many years; by the time he did, he already had a neurogenic bladder, an abnormal gait, and required a cane to ambulate. More subtle signs noted at that time were decreased sensation in both lower extremities and increased muscle tone. His histories reported then and over the succeeding years, although containing some unintentional inconsistencies, overall present a picture of progressive multiple neurological symptoms ultimately diagnosed as adrenomyeloneuropathy, which at least as likely as not were of service onset. Therefore, it is not necessary to further delay a final decision by attempting to further clarify the evidence, which is insufficient to support a denial. Instead, the evidence as it currently stands is essentially evenly balanced. As such, there is a sufficient basis on which to decide the claim, and service connection for adrenomyeloneuropathy is warranted. In reaching this determination, the benefit-of-the-doubt rule has been applied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Entitlement to Compensation under 38 U.S.C.A. § 1151 The Veteran has submitted a claim based on 38 U.S.C.A. § 1151, as an alternative theory of entitlement to related VA compensation benefits for symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel, now diagnosed as adrenomyeloneuropathy. In light of the grant of benefits described above, the Board concludes that the Veteran's 38 U.S.C.A. § 1151 claim is rendered moot. Entitlement to VA compensation under 38 U.S.C.A. § 1110 or § 1131, based on service connection, is the greater benefit, and it is granted in full. No additional benefit (monetary or otherwise) can be gained under 38 C.F.R. § 1151, nor does any controversy remain. See Hornick v. Shinseki, 24 Vet. App. 50, 53-57 (2010); Timberlake v. Gober, 14 Vet. App. 122 (2000). VA is only required to consider an appellant's claim under the provisions of 38 U.S.C.A. § 1151, if the Veteran's claim for service connection is denied under 38 U.S.C.A. § 1110. See, e.g., Timberlake, 14 Vet. App. at 134-35; Moffitt v. Brown, 10 Vet. App. 214, 224 (1997); Mintz v. Brown, 6 Vet. App. 277, 282-83 (1994). In light of the grant of service connection for adrenomyeloneuropathy, the claim for entitlement to VA compensation under 38 U.S.C.A. § 1151 is moot, and the claim is dismissed. IV. Higher Rating--Lumbar Spine Disability The Veteran's claim for service connection for a thoracolumbar back condition was received on August 15, 2003. Service connection for degenerative disc disease of the lumbar spine was granted in a February 2005 DRO decision, effective August 15, 2003, and this appeal ensues from the initially assigned 40 percent rating. The rating schedule for evaluating spine disabilities changed during the pendency of this appeal. Either the old or new rating criteria may apply, whichever are most favorable to the veteran, although the new rating criteria are only applicable since their effective date. VAOPGCPREC 3-2000; 65 Fed. Reg. 33422 (2000). The criteria pertaining to the evaluation of intervertebral disc syndrome were revised effective September 23, 2002 (67 Fed. Reg. 54345-54349 (2002)), followed by a revision of the entire section of the rating schedule pertaining to disabilities of the spine effective September 26, 2003. 68 Fed. Reg. 51,454-458 (Aug. 27, 2003); 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2004). The 2003 revisions did not result in any substantive changes from the 2002 revisions for the evaluation of intervertebral disc syndrome Under the old criteria, in effect prior to September 26, 2003, severe limitation of motion of the lumbar spine is rated 40 percent when disabling. 38 C.F.R. § 4.71a, Code 5292. Severe lumbosacral strain manifested by listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space, or some of the above with abnormal mobility on forced motion, warrants a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5295. The DRO granted the 40 percent rating under this Diagnostic Code. The revised regulations include a general rating formula for diseases and injuries of the spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Codes 5235-5243 (2012). As pertinent to the thoracolumbar spine, for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine, a 40 percent rating is warranted. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Id. Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. See Cullen v. Shinseki, 24 Vet. App. 74 (2010). The veteran has limitation of motion and spasms in the lumbar spine. However, ankylosis (favorable or unfavorable) has not been demonstrated, and the maximum rating provided, under either the new or old criteria, based on limitation of motion, is 40 percent. Therefore, the specific range of motion findings will not be further discussed. In this regard, as he is in receipt of the maximum rating based on limitation of motion, a higher rating may not be assigned for functional impairment, under that diagnostic code. See Johnston v. Brown, 10 Vet. App. 80 (1997). Under the general formula for rating back disabilities, any associated objective neurologic abnormalities are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Codes 5235-5243 Note (1). However, the evidence does not show neurologic symptoms or disability, due to his service-connected back condition, which would warrant a separate rating. In this regard, as noted above, his neurological manifestations, including of the bowel, bladder, and lower extremities, have now been attributed to the disease adrenomyeloneuropathy, for which service connection is granted in this decision. If the service-connected spinal disability is intervertebral disc syndrome, the back disability may be rated under alternate criteria. In this case, the service-connected disability is degenerative disc disease of the lumbar spine, although at the time of the diagnosis, in January 2005, an MRI scan in December 2004 had not shown any degenerative disc disease. Nevertheless, a more recent MRI in February 2011 revealed mild degenerative disc disease. The Board will address whether an increased rating could be granted, under the criteria pertaining to intervertebral disc syndrome. The old criteria for intervertebral disc syndrome, effective prior to September 23, 2002, are not for application in this case, because the date of claim was in August 2003. Under the new criteria, the alternate criteria provide for rating based on incapacitating episodes of intervertebral disc syndrome. When rated based on incapacitating episodes, different ratings are assigned based on the number and duration of incapacitating episodes, defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. A 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Here, the evidence does not show that bed rest has been prescribed by a physician for a thoracolumbar spine disability. On a VA examination in August 2010, the examiner stated that there were incapacitating episodes of spine disease, noting that the Veteran had spent much of the past year in bed, and had had a severe MRSA infection. Later in the examination report, the examiner said that the incapacitating episodes were not due to intervertebral disc syndrome. The examiner also stated that ankylosis was not present. Since that examination, the Veteran's neurological symptoms, including paraplegia, have been related to adrenomyeloneuropathy. Therefore, a higher rating is not warranted based on incapacitating episodes. Finally, with respect to whether referral for extraschedular consideration is warranted, the Board finds that the Veteran's back disability picture is contemplated by the rating schedule, which provides for higher evaluations for low back disorders. The evidence of record does not support limitation of activities, beyond that contemplated by the schedular evaluation in effect. All of the Veteran's symptomatology associated with his back disorder has been taken into account in the current assigned rating. As such, the schedular criteria are considered to be adequate; and because this is the case, it is not necessary to proceed to the second step, a discussion of whether the exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms," such as "marked interference with employment" and "frequent periods of hospitalization." See Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1). Therefore, the Board concludes the Veteran's low back symptoms do not more closely approximate a rating in excess of 40 percent. Further, such symptoms have not been demonstrated at any time during the appeal period. See Fenderson, 112 Vet. App. 119. In reaching this determination, the Board has considered the medical evidence of record, as well as lay statements and testimony. However, the etiology of the Veteran's neurological symptoms has been found to be due to another disease, adrenomyeloneuropathy. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. However, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). V. Entitlement to a TDIU Rating The Veteran claims entitlement to a TDIU rating, asserting that his service-connected disabilities prevent gainful employment. A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The service-connected disabilities which have been assigned ratings by the RO are posttraumatic stress disorder (PTSD), assigned a 50 percent rating; lumbar spine degenerative disc disease, assigned a 40 percent rating; residuals of cold injury to the feet, assigned a 20 percent rating for each foot; tinnitus, assigned a 10 percent rating; and noncompensably rated bilateral hearing loss. His combined disability rating is 80 percent. In addition, service connection has been granted in this decision for adrenomyeloneuropathy. The Board recognizes that the RO has not yet had an opportunity to assign an initial evaluation for adrenomyeloneuropathy, and, in general, the TDIU issue would be remanded for this action, prior to a decision. However, in this case, even without consideration of the adrenomyeloneuropathy, the Veteran meets the schedular criteria for a TDIU rating. See 38 C.F.R. § 4.16(a). Moreover, the symptoms of adrenomyeloneuropathy will still be considered, even if a rating has not been assigned. Thus, there is no prejudice in considering the TDIU rating at this time. According to a psychology assessment in December 1998, the Veteran was employed as a machinist until 1990, when pain in his feet and legs precluded him from working full time. He said that he worked at odd jobs intermittently until the previous year. His treating physician at the VA SCI clinic wrote, in August 2008, that the Veteran was a paraplegic and had severe service-connected back pain, and that in his opinion, the Veteran was unemployable and totally and permanently disabled. At his Board hearing in August 2009, the Veteran testified that he was trained for physical employment, but due to his foot, leg, and back problems, he could no longer work. A private vocational specialist wrote, in May 2005, May 2010, and March 2013, describing how, in his opinion, the Veteran was unable to engage in substantially gainful employment due to his service-connected disabilities. In contrast, there is no indication that the Veteran has been able to engage in substantially gainful employment at any point during the appeal period. Indeed, in a May 1999 rating decision, the RO found the Veteran to be permanently and totally disabled, as well as housebound, for pension purposes, due to his symptoms which have now been diagnosed as adrenomyeloneuropathy. This disease has continued to deteriorate, to the point where, in the most recent correspondence, dated in April 2013, it was indicated that he was in a hospice. Given these factors, the Board finds that the Veteran is unemployable, due solely to his service-connected disabilities, including adrenomyeloneuropathy. The requirements for a TDIU rating are met, and such benefit is granted, unless or until he is granted a 100 percent schedular evaluation, which would render a TDIU rating moot. See 38 C.F.R. §§ 3.341(a) , 4.16 (2012) (TDIU rating for consideration where schedular rating less than total). However, to ensure his entitlement to at least a TDIU rating as expeditiously as possible, a TDIU rating is granted, notwithstanding any subsequent rating decisions which may render such rating moot. ORDER Service connection for adrenomyeloneuropathy, manifested by symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel, is granted. The appeal seeking compensation under the provisions of 38 U.S.C.A. § 1151 for symptoms including chronic spastic paraplegia of the lower extremities with a neurogenic bladder and a neurogenic bowel, now diagnosed as adrenomyeloneuropathy, is dismissed. Entitlement to an evaluation in excess of 40 percent for lumbar spine degenerative disc disease is denied Entitlement to a TDIU rating is granted, subject to the laws and regulations governing the payment of VA compensation. REMAND The remainder of the issues require additional action before an appellate decision can be reached. As to the SMC claims on appeal, adrenomyeloneuropathy must be rated before these issues can be addressed, because entitlement is based, in part, on the ratings assigned for the service-connected disabilities. SMC is payable, at the "l" rate, to a Veteran whose service-connected disabilities leave him/her so helpless as to be in need of regular aid and attendance (A&A). 38 U.S.C.A. § 1114(l) (West 2002); 38 C.F.R. §§ 3.350(b)(3); 3.352(a) (2012). However, SMC is also available for other types and combinations of disabilities. For example, SMC based on paraplegia (paralysis of both lower extremities) together with the loss of anal and bladder sphincter control is entitled to the maximum rate under 38 U.S.C.A. § 1114(o) (i.e., payable at the "o" rate). 38 C.F.R. § 3.350(e)(2) (2012). Then, if a Veteran is granted SMC at the "o" rate and needs regular aid and attendance or a higher level of care, SMC at the "r" rate may be granted. 38 U.S.C.A. § 1114 (r)(1); 38 C.F.R. § 3.350(h). SMC may also be payable when the Veteran has a single service-connected disability rated as 100 percent and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.A. § 1114(s) (West 2002); 38 C.F.R. § 3.350(i). Housebound means that a claimant is restricted to his or her house, except for medical treatment purposes. Howell v. Nicholson, 19 Vet. App. 535 (2006). Therefore, after the RO has assigned the initial ratings, including any applicable SMC ratings based on types and combinations of disabilities, a decision must be made as to entitlement to SMC based on the need for aid and attendance, and, if granted, at what point during the appeal period this began. For housebound status, as a threshold requirement, the Veteran must have a single service-connected disability rated 100 percent disabling, but the housebound status is a lesser benefit than A&A, and, thus, will only be relevant if A&A is denied. For the issue of service connection for a cardiovascular condition, the evidence shows that in May 2001, the Veteran sought treatment after 27 hours of chest pain. He was found to have evidence of an extensive myocardial infarction. Initially, service connection was claimed on the basis that the heart condition was secondary to the service-connected back condition. However, given the recent diagnosis of a rare neurological disease, adrenomyeloneuropathy, for which service connection has been granted in this decision, the Board finds that an opinion should be obtained as to whether the cardiovascular disease was due to, or aggravated by, the adrenomyeloneuropathy. See Roebuck v. Nicholson, 20 Vet. App. 307 (2006), (multiple theories of entitlement pertaining to the same benefit for the same disability constitute the same claim); Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000) (VA's duty to assist a claimant with the development of evidence extends to all applicable theories of a claim). In this regard, the secondary claim as to the back was based on the argument that the decreased mobility caused by the back condition resulted in the Veteran's inability to exercise. However, adrenomyeloneuropathy is a systemic disease, with symptoms such as adrenal insufficiency; as such, the Board cannot dismiss any potential connection without a medical opinion. See Jones v. Principi, 16 Vet. App. 219, 225 (2002) (Board must provide a medical basis other than its own unsubstantiated conclusions to support its ultimate decision). For the issue of a higher rating for PTSD, service connection for PTSD was granted as secondary to degenerative disc disease, by aggravation. This was based on a VA examination in July 2010, and a supplemental opinion in June 2011, which noted that it seemed likely that the Veteran entered the military with many, if not all, of the symptoms of PTSD due to his long history of being physically abused by his father. The experience of chronic pain often leads to an ongoing heightened tendency toward irritability and an desire to withdraw from social activities, two symptoms of PTSD. In all likelihood, the chronic pain and disability associated with his degenerative disc disease aggravates his PTSD, making it more severe and difficult to treat than would otherwise be the case. The examiner estimated the Veteran's GAF score as 40, but then commented that the Veteran's chronic medical problems and chronic pain appeared to be primarily responsible for his psychosocial impairment and the PTSD had more influence on his behavioral expression. However, as service connection has now been granted for adrenomyeloneuropathy, with associated pain, VA must be careful to avoid rating this same manifestation under different diagnostic codes. See 38 C.F.R. § 4.14. Therefore, an opinion should be obtained as to the symptoms of PTSD which are not duplicative of his pain associated with service-connected disabilities, including degenerative disc disease and adrenomyeloneuropathy. Accordingly, the case is REMANDED for the following action: 1. Obtain VA medical records dated from dated from April 2012 to the present from the Albuquerque VAMC. 2. Issue a rating decision implementing service connection for adrenomyeloneuropathy, granted above in this decision, and assign a rating and effective date. In assigning the rating, review the rating decision dated May 19, 1999, which granted a 100 percent rating, for pension purposes, for "chronic spastic paraplegia of the lower extremities requiring the use of a wheelchair, with a neurogenic bladder requiring self catheterization and a neurogenic bowel." In view of that decision, a grant of less than 100 percent for adrenomyeloneuropathy must be supported by a detailed rationale which addresses all evidence in the Veteran's favor. * In addition to the schedular rating, all applicable SMC ratings must be assigned. In this regard, consideration must be given to entitlement to the maximum rate under 38 U.S.C.A. § 1114(o), based on paraplegia (paralysis of both lower extremities) together with the loss of anal and bladder sphincter control. See 38 C.F.R. § 3.350(e)(2). * Then, review the claim on appeal for SMC, based on A&A or at the housebound rate. If a 100 percent rating for adrenomyeloneuropathy is granted, at the same time, review the claim for SMC, to include to the based on the need for regular aid and attendance (A&A) or at the housebound rate. Again, in view of the May 1999 rating decision, which granted entitlement to special monthly pension on account of being housebound, due to the symptoms now diagnosed as adrenomyeloneuropathy. Again, in view of that decision, a denial of housebound status must be supported by a detailed rationale which addresses all evidence in the Veteran's favor. (This does not apply if housebound status is rendered moot based on the grant of an overlapping but higher SMC rate such as A&A.) * In view of the Veteran's precarious health, all grants of compensation, including SMC, should be implemented before proceeding to the following: 3. If the development requested above does not yield evidence sufficient to warrant a complete grant of the benefits sought as to the SMC issue, obtain an opinion as to whether the Veteran is bedridden or requires the regular aid and attendance of another person in activities of daily living due solely to his service-connected disabilities, which are adrenomyeloneuropathy, degenerative disc disease of the lumbar spine, PTSD, residuals of cold injury to the feet, tinnitus, and bilateral hearing loss, and, if so, at what point in time such assistance became necessary. The opinion should also address whether, due to the service-connected disabilities, standing alone, the veteran is "substantially confined" to his premises, i.e., restricted to his house except for medical treatment purposes. 4. Next, and after the above action is completed, obtain an opinion from an appropriate VA physician as to whether the Veteran's cardiovascular disease was at least as likely as not caused or aggravated (permanently worsened) by the now-service-connected adrenomyeloneuropathy. The claims files must be provided to the physician in connection with the opinion, and a rationale for the opinion should be included. 5. Forward the claims folders to a VA psychiatrist or psychologist for an opinion concerning the manifestations of PTSD. In view of the Veteran's fragile health, an examination should be obtained only if it is deemed necessary. The opinion should attempt to differentiate the psychiatric symptoms of PTSD from symptoms of pain which would be rated as part of the underlying disabilities causing the pain, e.g., degenerative disc disease and adrenomyeloneuropathy. The rationale for the opinion shall be provided. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so, to include whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 6. After assuring compliance with the above development, as well as with any other notice and development action required by law, the RO should review the claims for SMC based on A&A or housebound status; service connection for a cardiovascular disability; and a higher initial evaluation for PTSD. If the decision as to any issue is less than a full grant of the benefit sought, furnish the Veteran and his representative with a supplemental statement of the case, and provide an opportunity for response, before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs