Citation Nr: 1325621 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 10-27 251 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Entitlement to an evaluation greater than 20 percent for lumbar spine arthritis. 2. Entitlement to an evaluation greater than 20 percent for cervical spine arthritis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, S.M., and K.G. ATTORNEY FOR THE BOARD M. Carsten, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. In July 2011, the Veteran testified before the undersigned Veterans Law Judge (VLJ) sitting at the RO. A transcript of that hearing is associated with the record. In December 2011, the Board denied entitlement to increased evaluations for arthritis of the lumbar and cervical spines. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). By Order dated in July 2012, the Court granted a Joint Motion for Remand (joint motion). In March 2013, the Board remanded the appeal for additional development. The case has since returned to the Board. The Virtual VA eFolder has been reviewed. FINDINGS OF FACT 1. The Veteran's lumbar spine arthritis is manifested by functional loss more nearly approximating forward flexion limited to 30 degrees or less. The disability is not manifested by unfavorable ankylosis of the entire thoracolumbar spine, and does not cause incapacitating episodes as defined by VA. 2. The Veteran's cervical spine arthritis causes some limitation of motion and pain, but does not limit forward flexion to 15 degrees or less, does not cause ankylosis, favorable or unfavorable, of the entire cervical spine, and does not cause incapacitating episodes as defined by VA. CONCLUSIONS OF LAW 1. The criteria for a 40 percent rating, and no more, for lumbar spine arthritis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2012). 2. The criteria for a rating greater than 20 percent for cervical spine arthritis have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. By letters dated in October 2009 and February 2010, VA notified the Veteran of the information and evidence needed to substantiate and complete a claim for increase, to include notice of what part of that evidence is to be provided by the claimant and notice of what part VA will attempt to obtain. These letters also provided notice of how VA assigns disability ratings and effective dates. Throughout the appeal, the Veteran has been advised of applicable rating criteria. The claims were most recently readjudicated in the May 2013 Supplemental Statement of the Case. VA has also satisfied its duty to assist. The RO has made reasonable and appropriate efforts to assist the appellant in obtaining the evidence necessary to substantiate these claims, including requesting information from the appellant regarding pertinent medical treatment he may have received. In regard to medical treatment, pertinent VA treatment records have been obtained. As far as private medical treatment, the Veteran testified in July 2011 that he has received some private medical treatment, but that "pretty much most of it" was unavailable. He said that he had been seeing a private chiropractor, Dr. W., at VA's expense, but that Dr. W. was getting ready to move out of the area. The record shows that there is a letter from Dr. W. from the Aware Wellness Center on file dated in June 2010. The record also shows that adequate attempts were made to obtain the actual fee basis treatment records from Dr. W. but to no avail. See VA Memorandum dated in January 2010. Additionally, in February 2011, the RO asked the Veteran to submit an authorization for chiropractic records from Dr. W., but to date, this has not been received. The Veteran was provided VA examinations in March 2010 and February 2011. As set forth in the joint motion, and pursuant to the March 2013 remand, the RO was to return the March 2010 examination and request clarification of the previous report. Specifically, the examiner was requested to provide the range of motion limitations (in degrees) in the lumbar and cervical spines due to pain. Additional VA examination was provided in April 2013. This examination was not provided by the same examiner that conducted the March 2010 examination and the Board assumes VA was unable to obtain clarification of the March 2010 findings. The recent examination specifically addressed functional impairment due to painful motion and other factors, and also set forth post-test range of motion in degrees. This examination is adequate for rating purposes and the Board finds sufficient compliance with the previous remand directive. See Dyment v. West, 13 Vet. App. 141 (1999). The Veteran was also afforded an opportunity to present testimony at a hearing before the Board. The actions of the VLJ during the hearing supplement the VCAA and comply with any related duties owed during a hearing. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Factual Background In a February 1978 rating decision, the RO granted service connection for cervical and lumbosacral spine strain and assigned a noncompensable rating. The RO increased this rating to 20 percent in January 1986. Private treatment records from St. Joseph Hospital show that the Veteran received physical therapy treatment from January 2006 to July 2007 for back pain which he said he had had since an accident in November 2005 when he struck a deer while driving his vehicle. A magnetic resonance imaging (MRI) revealed L-4 and L-5 compressed discs. In October 2006, the Veteran filed a claim for an increased rating for his back disability, asserting that he had increased back pain and was unable to stand for any length of time. He also said that his legs get numb and he is unable to "stoop over." He said he had been involved in an automobile accident in November 2005 and had to be air lifted to a hospital. In a rating decision dated in June 2007, the RO recharacterized the Veteran's cervical and lumbar disability by separating them into two disabilities, i.e., cervical spine arthritis and lumbar spine arthritis, and assigned two separate 20 percent evaluations. VA lumbar spine x-rays in May 2009 revealed degenerative osteoarthritis, and a lumbar MRI in December 2009 likewise revealed degenerative osteoarthritis, most pronounced at the facet joints. Degenerative joint disease is noted on a VA March 2010 lumbar x-ray report, and a March 2010 VA cervical x-ray report shows scoliosis, osteopenia, degenerative joint disease and degenerative disc disease. VA outpatient records also show that the Veteran experienced an exacerbation of low back pain in April and May 2009 after hitting a deer in his vehicle. A May 2009 VA chiropractic consult shows forward flexion of the lumbar spine limited to 30 degrees. In October 2009, the Veteran filed a claim for increased ratings for his back disabilities, asserting that the conditions had worsened. He reported receiving treatment at a VA medical center (VAMC) in Ft. Harrison and at the Wellness Clinic in Polson. The Veteran underwent a VA examination for his back on March 5, 2010. The examiner indicated that he did not have the Veteran's claims file to review. With respect to his cervical spine, the examiner relayed the Veteran's report that his neck was becoming worse and painful. He described the pain as constant and dull. He also reported flares of pain if he slept wrong or with bad weather. He reported intense knotted muscles in the back of his neck and said he treats his neck with hot and cold packs, physical therapy, Etodolac and Darvocet. He said the Darvocet does not work and causes nausea. He said his neck pain causes migraine headaches. He described his occupational work as a part-time consultant writing anti-viral computer programs which he sells to the market. He said he can no longer lift a computer monitor or modem. He reported using no assisted mobility devices, but said after sitting or driving for long periods of time he has to "stop". He reported having a steady balance and was able to perform all activities of daily living, but had trouble bending as well as tying and picking up his shoes. Examination findings in March 2010 showed that the Veteran had normal curvatures of the cervical spine and it was symmetrical in appearance. Range of motion included forward flexion from 0 to 35 degrees, extension from 0 to 45 degrees, left lateral flexion from 0 to 20 degrees and right lateral flexion from 0 to 20 degrees. Left lateral rotation was from 0 to 70 degrees and right lateral rotation was from 0 to 70 degrees. Range of motion was not limited by fatigue, weakness, or lack of endurance following repetitive use. There was objective evidence of painful motion with the Veteran groaning frequently during the examination, but no objective evidence of spasm or weakness. The Veteran reported tenderness to palpation of the entire cervical area. Cervical spine x-ray findings revealed moderate osteopenia and severe arthritic spur formation with a chronic appearing 10% anterior wedge compression deformity of C5 with attendant arthritic spur formation indicating old trauma and secondary degenerative change. There was also degenerative disc disease in C5/C6 with a 10% compression deformity of C5 and C6 indicative of old trauma and secondary degenerative change. The Veteran was assessed as having cervical spine degenerative joint disease and degenerative disc disease and wedge compression with osteopenia. The examiner opined that the wedge compression was at least as likely as not due to the Veteran's fall in service where he reported falling 40 feet. With respect to his lumbar spine, the Veteran reported that he had aggravated his low back after hitting a white tail deer approximately 7-8 years earlier. He said he had been told at that time he had torn a ligament in his back. He said he also hit a deer in late December, but was not treated at that time. He denied undergoing any surgery for his low back and said he treated his low back with physical therapy and chiropractic treatment. He reported experiencing back pain whenever driving more than two hours or walking more than two minutes without help. He said the low back pain occurred on the left side of his back to his tailbone, but did not radiate to the bilateral legs. He said he had used morphine and Demerol in the past which helped stop the pain, and presently took Etodolac which helps with the pain, but upsets his stomach. He added that he uses Darvocet which takes the edge off of the pain. He said he could not pull up a floor jack to lift his vehicles and had recreational limitations such as being unable to hunt or fish except from his vehicle. He said he has difficulty pushing a lawnmower or snow blower. He denied any associated weight loss, fevers, malaise, dizziness, visual disturbances, numbness, weakness, or bowel or bladder complaints other than increased bladder urgency and flatus. He said he had a penis prosthesis which was due to his in-service back injury. He denied using ambulatory aids and reported poor balance. He reported having an "incapacitating episode" on one occasion when, while attending a "veterans stand down" in October 2009, he lost his balance and fell. He said he was seen in the dispensary, received aspirin and was told to lie down. He was noted as having no history of surgery and was able to ambulate, transfer and perform activities of daily living. On examination, the examiner noted that range of motion measurements failed to match known pathology. Forward flexion was from 0 to 60 degrees, extension was from 0 to 20 degrees, left lateral flexion was from 0 to 20 degrees and right lateral flexion was from 0 to 20 degrees. In addition, right and left lateral rotation was from 0 to 30 degrees on each side. The exam revealed that range of motion was partially limited by complaints of pain, and there was no evidence of fatigue, spasms, weakness or lack of endurance following repetitive use. There were complaints of localized tenderness on palpation of the low back and sacroiliac joints. There was no guarding, spasm, weakness or atrophy. The examiner reported that there was no objective or clinical evidence to show any additional limitation of joint function due to pain, fatigue, weakness, or lack of endurance following repetitive use with three joint measurements beyond the measured and reported ranges for all joints reported on the examination. Lumbar spine imaging revealed degenerative joint disease and the report notes that the results showed no change from prior imaging conducted in May 2009. The Veteran was diagnosed as having degenerative joint disease of the lumbar spine - moderate. Also noted by way of a MRI in December 2009 was moderate degenerative arthropathy. The examiner stated that the Veteran had a 10% loss of height at T12 which was consistent with a compression deformity most likely a result from the fall in service, and said no change was reported by radiology from lumbar spine imaging dated in May 2009. The examiner also reported no change since the Veteran's reported motor vehicle accident with a deer in December 2009. VA outpatient records show that the Veteran underwent a chiropractic consult on March 30, 2010 for chronic low back and neck pain. He reported that his pain was exacerbated with standing, walking, or lifting. Objectively, lumbar range of motion was reported as flexion to 20 degrees, extension to 5 degrees, and lateral flexion bilaterally to 5 degrees with pain in all planes. Cervical spine range of motion was reported as flexion to 40 degrees, extension to 20 degrees, right rotation to 45 degrees, and left rotation to 40 degrees. Soft tissue palpation revealed pain and tenderness at the mid thoracic, lower cervical and lower lumbar spines. On file is a letter dated in June 2010 from O.M.W., D.C, who said he had been seeing the Veteran for low back pain for a year under VA authorization. He explained that the Veteran suffered on a daily basis from his back condition and some days were better than others. He said the Veteran frequently rated his pain as an eight or nine out of 10 and his activities of daily living were "very much compromised" by his condition. He said his treatment of conservative adjusting at various levels and application of trigger point therapy offered the Veteran, at best, temporary relief. He concluded by opining that chiropractic care was not a "viable" long term option for the Veteran and recommended that the Veteran look into other alternatives of treatment not within his scope of practice. In his substantive appeal dated in June 2010, the Veteran said he was not able to do any work such as lifting more than 10 pounds onto a work space. He also said he had trouble standing or walking for any distance without help and could not mow the lawn without severe pain. VA outpatient records from November 2010 to February 2011 include a February 2011 record listing the Veteran's active problems as including chronic low back pain and degeneration of lumbar or lumbosacral intervertebral disc post motor vehicle accident November 2005. At a VA examination in February 2011, the Veteran reported daily, intermittent low back pain which he assessed as a four or five on a pain scale to 10 and described the pain as moderate. He also reported 12-13 occasions of incapacitating episodes in the last month that required bed rest. He said he takes Etodolac twice daily for back pain and cyclobenzaprine as a muscle relaxer. He reported flare-ups of back pain one to two times a week and said that during such flare ups he has to lie down. He reported that his pain was exacerbated when he hit a deer (in his vehicle) six years earlier, and after shoveling snow. He denied using an ambulatory device or brace. He said he is limited to walking about 25 feet prior to the onset of back pain and was limited to standing one minute. He can perform the activities of daily living independently, but with caution and standing in the shower is difficult. He added that he has to change position after driving for 20 minutes. On examination the Veteran's posterior musculature appeared symmetrical with erect posture and an even gait. Curvature of the lumbosacral spine was normal. There was no evidence of abnormal angulation of the knees when standing with ankles together. There was no evidence of pain on palpation over the sciatic nerve bilaterally. Reflexes were patellar - 2+, Achilles - 2+, babinski-downgoing toes bilaterally, and clones - negative bilaterally. Straight leg raising was to 90 degrees bilaterally without complaint of pain. Laseque's sign was negative bilaterally (presence or worsening of radicular pain). Muscle strength was 5/5 for hip abduction, iliopsoas flexion, knee flexion/extension and ankle dorsi flexion/plantar flexion. Lumbar spine ranges of motion from a standing position were as follows: forward flexion 0 to 60 degrees; extension 0 to 20 degrees; left and right lateral flexion 0 to 20 degrees on each side; and left and right lateral rotation 0 to 25 degrees on each side. Regarding Deluca considerations, the examiner stated that there was no objective (or clinical) evidence to show any additional functional loss of range of motion due to pain, weakened movement, excess fatigability or incoordination beyond the measured and reported ranges. He added that there was no objective evidence of pain with motion at the above-noted degrees as evidenced by facial grimace or Veteran's comment. He said there was no objective evidence of painful motion, edema, effusion, instability, weakness, abnormal movement or guarding of movement, and no objective evidence of poor muscle tone or atrophy. He added there was no clinical evidence of pain, radiating pain, fatigue, weakness, lack of endurance or incoordination, muscle spasm, guarding or localized tenderness. In addition, he said there was preserved spinal contour and normal gait, and no clinical evidence of postural abnormalities, fixed deformity (ankylosis), or abnormality or musculature of back. He went on to note no clinical evidence of additional limited joint function with repetitive use due to pain, fatigue, weakness, lack of endurance or incoordination. He said the Veteran did display poor coordination with heel, toe, tandem, and BW walk, and was unable to stand on one leg and do repetitive shallow knee bends without loss of balance. He also noted that the Veteran was unable to squat and return to standing position without complaining of pain or loss of balance. Cervical x-ray findings revealed advanced degenerative changes in the lower cervical spine. Lumbar spine x-ray findings revealed degenerative disc disease which was overall mild, with severe facet degenerative change bilaterally at L5-S1. Regarding his neck, the Veteran reported constant neck pain at the base of his head and assessed the pain as a three on a pain scale to 10. He said that weather changes cause flare-ups which require him to lie on a heating pad. He reported associated neck stiffness. He remarked that he has to change position when driving. He said he takes Naprosyn and Etodolac. On examination the position of the Veteran's head was neutral, not rigid. His head moved back and forth with conversation and curvatures of the spine were normal and symmetrical in appearance. His neck was non-tender to palpation. Range of motion revealed forward flexion from 0 to 35 degrees, extension from 0 to 40 degrees, left lateral flexion from 0 to 25 degrees, right lateral flexion from 0 to 25 degrees, left lateral rotation from 0 to 70 degrees and right lateral rotation from 0 to 70 degrees. Range of motion was not limited by fatigue, weakness or lack of endurance following repetitive use. There was no objective evidence of pain at the above-noted degrees as evidenced by facial grimace or Veteran's comment. There was also no objective evidence of painful motion, spasm, weakness or tenderness. In regard to Deluca considerations, the examiner reported that there was no objective evidence to show any additional functional loss of range of motion of the cervical spine due to pain, weakened movement, excess fatigability, beyond the measured and reported ranges. Neurological findings were unremarkable. Regarding employment, the Veteran told the examiner he was in computer repair, software and hardware development which required lifting of equipment, modems and towers ranging in weight from five pounds to 40 pounds. At a Board hearing conducted at the RO in July 2011, the Veteran testified that he has a hard time when he wakes up due to neck and back pain and he uses a heating pad that VA issued to him. He said he self-medicates with herbs from the woods. He said he experiences "bad" neck stiffness which he alleviates by moving his head around. He said he also experiences back stiffness which he similarly alleviates by moving around. He said he was basically retired, but buys old computers which he reconditions and refurbishes and donates to kids. He said he lays down eight to 10 times a day for about 15 to 30 minutes, due to neck or back pain. He assessed his pain as starting off around a three or four (out of 10) and increases to a six to eight. He reported flare-ups and said the pain was worse in the winter. He said he has to stay in bed during flare-ups which can last from a good three to four days in the winter. He said he was unable to lift anything over 20 pounds. He also reported experiencing numbness in his legs, more so on the right, which affects his balance. He said his doctor thought that this was due to arthritis. He also said he can tolerate standing for four to five minutes at a time and can sit for a good two to three hours. He said he can do chores around the house like washing dishes, but it takes him a long time. The Veteran's friend, S.M., testified that he has witnessed the Veteran collapse after standing too long and that the Veteran's condition has worsened considerably over the last 10 years. Another friend of the Veteran, K.G., testified that she watched the Veteran go from a very active person to a totally inactive person. She agreed that the Veteran's condition had progressively worsened over the past eight years in which she has known him. On file is a letter from C. B., D.C., dated in September 2011, who reported that the Veteran has been an on and off again patient for many years. He said the Veteran's spine was diminished, displaced and had a greatly reduced range of "moment". He relayed the Veteran's report of headaches and peripheral neuralgia from the neck into the arms. He said that chiropractic has helped the Veteran, but that his condition was chronic and deteriorating. He added that at times the Veteran was barely ambulatory. He said the Veteran complained of numbness and pain in his legs and into his feet and had difficulty getting from sitting to standing. He said the Veteran's prognosis was poor with little chance of regaining normal functions. He also said that physical therapy was too strenuous for the Veteran so he recommended less strenuous but effective exercises. VA records dated from approximately March 2011 to March 2013 show continued complaints of chronic low back pain. In July 2011, the Veteran was carrying a computer monitor and apparently fell. There was soreness in the L4-S1 area. Objectively, range of motion of the lumbar spine was decreased and guarded. He could, however, touch his knees and extend to neutral. Rotation was symmetric, but side bending was guarded and limited. Impression was acute on chronic low back pain, exacerbated with increased activity and fall. In February 2012, he was seen in the emergency room for complaints of pain following a fall. Objectively, his back was nontender and x-rays were negative for vertebral fracture. Impression was musculoskeletal back pain after a mechanical fall. In September 2012, the Veteran called to report that he had been moving a lot of furniture and his lower back hurt. A March 2013 VA telephone encounter documents the Veteran's report that he fell in the snow the day prior and was sore and stiff. He was advised to continue with anti-inflammatories and get in a warm shower. The Veteran most recently underwent a VA examination in April 2013. The Veteran's claims folder was reviewed and pertinent records were discussed. With regard to the thoracolumbar spine, diagnosis was degenerative arthritis of the lumbar spine. The Veteran reported flare-ups occurring more than once a day and dependent on activity or position. Range of motion of the lumbar spine was: forward flexion to 50 degrees, with painful motion beginning at 10 degrees (based on facial grimace and positional guarding); extension to 0 degrees with painful motion beginning at 0 degrees (based on facial grimace and positional guarding); right lateral flexion to 10 degrees, with painful motion beginning at 10 degrees (based on facial grimace); left lateral flexion to 20 degrees, with painful motion beginning at 20 degrees (based on facial grimace); right lateral rotation to 20 degrees, with painful motion beginning at 20 degrees (based on facial grimace); and left lateral rotation to 20 degrees, with painful motion beginning at 20 degrees (based on facial grimace). The examiner noted, however, that the Veteran was able to sit in a chair which requires a minimum of 56-66 percent of lumbar flexion. With regard to DeLuca, the examiner noted that the Veteran subjectively reports pain. On examination there was no clinical evidence of weakness, fatigability and/or incoordination that would significantly limit functional ability during the described flare-ups, or when the spine is used repeatedly over a period of time. There was no clinical/objective evidence of additional limitation due to claimed flare-ups beyond the measured and reported ranges. The examiner, however, also stated that range of motion documents limitation of spine function with repeated use. The Veteran was unable to perform repetitive flexion and extension movements secondary to subjective report of pain in the back and weakness in the legs. The Veteran was unable to perform the initial spinal flexion and extension without bracing himself on the exam table. Post-test range of motion in the remaining planes was reported as: right lateral flexion to 10 degrees; left lateral flexion to 20 degrees; right lateral rotation to 20 degrees; and left lateral rotation to 20 degrees. The examiner stated there was additional limitation in range of motion following repetitive use testing and that the Veteran did have functional loss and/or impairment of the thoracolumbar spine. The additional functional limitations were attributed to excess fatigability, incoordination, and pain on movement. The examiner noted exaggerated pain responses to palpation of the spine and paravertebral muscles. Impression management was suspected. There was guarding and/or muscle spasm but it did not result in abnormal gait or spinal contour. Muscle strength testing was 4/5. There was no muscle atrophy. Reflexes were 1+ throughout the lower extremities. Straight leg raising test results were positive on both sides and the examiner noted radiculopathy. X-rays of the lumbar spine showed (1) mild diffuse degenerative disc changes, stable from remote; and (2) pronounced facet degenerative change most evident at L4-5 and severe at L5-S1, stable. The Veteran reported that he has a back brace that no longer fits so he does not wear it. He uses a belt to help cinch his back. He uses a cane on a regular basis for stability and balance and uses a motorized cart for shopping at larger stores. The examiner stated that the Veteran's thoracolumbar spine condition did not impact his ability to work. Regarding the cervical spine, diagnosis was degenerative arthritis of the cervical spine. The claims folder was reviewed and relevant records were discussed. The Veteran reported that he could not flex or extend without increased pain. His neck hurts all of the time. He can only sit for about 30 minutes before he needs to stretch his neck. He has a hard time with overhead activities and feels off balance. The Veteran reported a flare after a recent fall and that he mainly experiences flare-ups when it is really cold and the neck becomes more painful and stiff. Range of motion of the cervical spine was: flexion to 30 degrees, with painful motion beginning at 30 degrees (based on facial grimace); extension to 10 degrees, with painful motion beginning at 10 degrees (based on facial grimace); right lateral flexion to 40 degrees, with no objective evidence of painful motion; left lateral flexion to 40 degrees, with no objective evidence of painful motion; right lateral rotation to 70 degrees, with no objective evidence of painful motion; and left lateral rotation to 70 degrees, with no objective evidence of painful motion. With regard to DeLuca, the examiner stated that the Veteran subjectively reports pain but on examination there was no clinical evidence of weakness, fatigability, and/or incoordination that would significantly limit functional ability during the Veteran's described flare-ups, or when the spine is used repeatedly over a period of time. There is no clinical or objective evidence of additional limitation due to claimed flare-ups beyond the measured and reported ranges. Range of motion documents limitation of spine function with repeated use, but does not limit joint function any further than documented ranges reported on examination. The Veteran was able to perform repetitive-use testing and post-test range of motion was reported as forward flexion to 30 degrees; extension to 10 degrees, right lateral flexion to 40 degrees, left lateral flexion to 40 degrees, right lateral rotation to 70 degrees, and left lateral rotation to 70 degrees. There was no additional limitation in range of motion following repetitive use testing and any functional loss was attributed to pain on movement. There was no localized tenderness or pain to palpation and no guarding or muscle spasm of the cervical spine. Muscle strength testing in the upper extremities was 5/5 and there was no muscle atrophy. Upper extremity reflexes were reported as 2+ throughout, and sensory examination was normal. Laws and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155;38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Franscisco v. Brown, 7 Vet. App. 55 (1994). Here the disability has not significantly changed and a uniform evaluation is warranted. Under the General Rating Formula, a 20 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is assigned for unfavorable ankylosis of the entire cervical spine or forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Note 5 to the General Rating Formula defines unfavorable ankylosis as including fixation of the spine or a portion thereof in flexion or extension, while fixation in a neutral position represents favorable ankylosis. In addition, Note (1) to the General Rating Formula provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. Note (2) (See also Plate V.) provides that for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3) states that in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) provides that each range of motion measurement be rounded to the nearest five degrees. Note (6) provides that disabilities of the thoracolumbar and cervical spine segments are to be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. When assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202, 204-7; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Analysis At the outset, as is indicated below, there is no evidence of unfavorable ankylosis of the Veteran's lumbar and cervical spine segments to warrant a single disability rating. See 38 C.F.R. § 4.71a, Code 5242, Note (6). Lumbar spine arthritis As an initial matter, the Board notes that the Veteran reported an exacerbation of low back pain following a motor vehicle accident in November 2005 when the vehicle he was riding in hit a deer. In this regard, the Board finds that it is not possible to separate the effects of the Veteran's service-connected lumbar arthritis from any non-service-connected lumbar symptomatology. Consequently the benefit of the doubt doctrine described in 38 C.F.R. § 3.102 dictates that such signs and symptoms be attributed to the service-connected lumbar spine arthritis. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 61 Fed. Reg. 52698 (Oct. 8, 1996)). The Board accepts that the appellant is competent to report, as he has in his statements, hearing testimony and to medical personnel, that he has pain, morning stiffness, and must adjust his position-sitting, standing, driving, etc-due to back discomfort. The appellant is further competent to report that those symptoms have worsened over the years. Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). However, with respect to his assertions that such symptoms warrant a higher rating for his lumbar spine arthritis, the Board must reiterate, as is noted above, that disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Pertinent rating criteria provide for a 40 percent evaluation when forward flexion of the thoracolumbar spine is limited to 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine. See General Rating Formula. Regarding forward flexion, this was shown to be 60 degrees on both the March 2010 and February 2011 VA examinations. While some limitation due to pain was noted, there was no objective or clinical evidence to show functional loss of range of motion due to pain or other factors beyond the stated range of motion. A May 2009 VA chiropractic consult, however, reported flexion to 30 degrees and a March 2010 VA chiropractic consult reported flexion to only 20 degrees with pain. A September 2011 private chiropractic statement indicates greatly decreased range of "moment," presumed to mean movement. The most recent VA examination showed forward flexion to 50 degrees, with painful motion beginning at 10 degrees. The Veteran was unable to perform repetitive use testing in both flexion and extension secondary to complaints of pain. The recorded ranges of motion (lumbar flexion to 30 degrees and 20 degrees) shown on the referenced chiropractic consults appears inconsistent with those findings shown on VA examinations during the appeal period. The Board, however, finds no legitimate basis for doubting the credibility of the VA chiropractic findings. Regardless, there is other evidence of record showing limitation of lumbar spine function, particularly on repeated use. This includes VA outpatient records showing complaints of chronic back pain with repeated falls and exacerbations. Range of motion is frequently described as decreased and guarded. Additionally, chiropractic and lay statements suggest increased disability resulting in some limitations of the activities of daily living and other functional impairment. Recent examination documents the need for assistive devices. Resolving reasonable doubt in the Veteran's favor, the Board finds the functional loss related to the overall lumbar spine disability to more nearly approximate the criteria for a 40 percent rating requiring limitation of flexion to 30 degrees or less. There is no evidence of unfavorable ankylosis of the entire thoracolumbar spine and a 50 percent rating is not warranted under the General Rating Formula. The Board has also considered the possibility of a higher schedular rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, which provides for a 60 percent rating for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. See Formula for Rating IVDS Based on Incapacitating Episodes, Note (1). The most recent VA examination indicated that there was no IVDS of the thoracolumbar spine. Nonetheless, the Board has considered the Veteran's reports of falling and of the need for bed rest. Evidence of record, however, does not support a finding of incapacitating episodes as defined by VA regulations. That is, the bed rest appears self-imposed and there is no evidence that is was prescribed by a physician, and certainly not for at least 6 weeks for the past 12 months. An evaluation greater than 40 percent is simply not warranted based on claimed incapacitating episodes. As set forth, the General Rating Formula directs that associated objective neurologic abnormalities be separately evaluated. The April 2013 thoracolumbar spine examiner included a diagnosis of mild and chronic sensorimotor axonal polyneuropathy consistent with diabetic polyneuropathy, bilateral lower extremities based on EMG/NCS study, not caused by or related to degenerative arthritis of the lumbar spine. Notwithstanding, in May 2013, the RO granted service connection for right lower extremity radiculopathy and left lower extremity radiculopathy. Each extremity was assigned a 10 percent evaluation effective April 16, 2013. To date, the Veteran has not disagreed with this decision and the Board does not find these issues for consideration at this time. The Board also finds no basis for any additional evaluations based on associated neurologic abnormalities. That is, objective evidence of record not show bowel or bladder impairment related to lumbar spine arthritis. Cervical spine arthritis The Board accepts that the appellant is competent to report, as he has in his statements, hearing testimony and to medical personnel, that he has pain, morning stiffness, and must adjust his position-sitting, standing, driving, etc-due to back discomfort. The appellant is further competent to report that those symptoms have worsened over the years. Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). However, with respect to his assertions that such symptoms warrant a higher rating for his cervical spine arthritis, the Board must reiterate, as is noted above, that disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Turning to the pertinent rating criteria, a 30 percent rating under the General Rating Formula is not warranted for the Veteran's cervical spine arthritis because the evidence reflects that there has been no ankylosis, favorable or otherwise, of the entire cervical spine or forward flexion of the cervical spine 15 degrees or less during the appeal period. The March 2010 and February 2011 VA examination reports include range of motion findings for flexion, extension, bilateral lateral flexion, and bilateral rotation of the cervical spine. This evidence reflects that there was reduced cervical spine range of motion, but to 35 degrees on forward flexion at both the March 2010 and February 2011 VA examinations. On VA examination in April 2013, forward flexion was to 30 degrees with pain beginning at 30 degrees. The absence of forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine precludes a rating higher than 20 percent for the Veteran's cervical arthritis under the General Rating Formula. In this case, the March 2010 VA examiner reported that range of motion was not limited by fatigue, weakness or lack of endurance following repetitive use, but he did find objective evidence of painful motion with the Veteran groaning frequently during the examination. The February 2011 VA examiner found no objective or clinical evidence to show additional functional loss of range of motion due to pain, weakened movement, excess fatigability or incoordination beyond the measured and reported ranges. The April 2013 VA examiner noted functional loss due to pain, but specifically stated that there was no additional limitation in range of motion of the cervical spine following repetitive use testing. For example, post-test forward flexion remained to 30 degrees. Additionally, the examiner noted that there was no clinical or objective evidence of additional limitation due to claimed flare-ups beyond the measured and reported ranges. Thus, while there is some evidence of functional loss due to painful motion, the Board does not find that such functional loss approximates the criteria for a 30 percent rating requiring limitation of forward flexion to 15 degrees. That is, there is no reliable evidence that any Deluca factor, to include pain, functionally limits forward flexion of the cervical spine to 15 degrees or less. Moreover, there is no evidence of ankylosis of the entire cervical spine, either favorable or unfavorable. The Board has also considered the possibility of a higher schedular rating under the Formula for Rating IVDS Based on Incapacitating Episodes, which provides for a 40 percent rating for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. However, these criteria have not been met. The April 2013 VA examiner indicated that there was no IVDS of the cervical spine. The Board further notes that despite the Veteran's reports, there is no objective evidence of incapacitating episodes as defined by VA. Thus, a rating higher than 20 percent is not warranted under these criteria. Again, the Board acknowledges that any associated objective neurologic abnormalities are to be rated separately. While consideration has been given to the September 2011 letter from chiropractor C. B., D.C., noting the Veteran's complaints of peripheral neuralgia from the neck into the arms, consideration has also been given to the cervical neurological findings at the March 2010, February 2011, and April 2013 VA examinations, which were unremarkable. The April 2013 examiner stated that the Veteran did not have radiculopathy or other neurologic abnormalities related to the cervical spine. In short, the Board finds that the Veteran's statements as to his symptoms are competent and credible; however, where these statements have conflicted with the findings on examination, the Board finds that the objective examination findings of the trained health care professionals to be more probative and entitled to greater weight than the Veteran's lay statements. Based on this evidence, a separate disability rating for such symptoms is not warranted. For the foregoing reasons, the Board finds that the evidence does not warrant a rating in excess of 20 percent for the Veteran's cervical spine arthritis during the pendency of this appeal. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C.A. § 5107. Extraschedular consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F. 3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The discussion above reflects that the symptoms of the Veteran's lumbar and cervical spine arthritis are contemplated by the applicable rating criteria, which take account of the loss of range of motion of the lumbar and cervical spines, sciatica, and lack of ankylosis and incapacitating episodes. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. Thus, the above evidence reflects that compensation in the form of an extra-schedular rating is not warranted, and there is no indication that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of an extraschedular evaluation for the Veteran's lumbar and cervical spine arthritis is not warranted. 38 C.F.R. § 3.321(b)(1). The Veteran reported that he was basically retired, but bought and refurbished old computer equipment for donation. Evidence of record does not suggest that the Veteran is unable to obtain or maintain substantially gainful employment due to his service-connected disabilities and at this time, the Board declines to infer a claim of entitlement to a total disability rating based on individual unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A 40 percent evaluation, and no more, is granted for lumbar spine arthritis, subject to the laws and regulations governing the award of monetary benefits. An evaluation greater than 20 percent for cervical spine arthritis is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs