Citation Nr: 1330463 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 07-23 944 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an initial disability rating in excess of 20 percent for lumbosacral strain with sacroiliac disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from September 1983 to August 1990 and from September 1992 to September 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, that granted service connection and a 10 percent rating for lumbosacral strain, effective in October 2005, the day following retirement from service. In February 2007, the RO in Columbia, South Carolina, granted an increased staged rating of 20 percent for lumbosacral strain, effective in November 2006, the date of a VA examination. The RO in Montgomery, Alabama has current jurisdiction of this claim. The Veteran testified at a hearing before the Board by videoconference sitting at the RO in Montgomery in June 2011. A transcript of the hearing is associated with the claims file. In December 2011, the Board remanded the claim for further development. In August 2010, the RO granted an initial rating of 20 percent for lumbar strain with sacroiliac disorder, effective in October 2005, the day following retirement from service. The Virtual VA paperless claims processing system does not contain additional evidence relevant to this appeal. FINDING OF FACT The Veteran's lumbosacral spine strain with sacroiliac disorder is manifested by limitation of thoracolumbar spine flexion greater than 30 degrees with no ankylosis or peripheral neurologic disease. CONCLUSION OF LAW The criteria for an initial rating in excess of 20 percent for lumbosacral strain with sacroiliac disorder are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242, 5243 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Notice must be provided to a claimant before the initial unfavorable decision on the claim for VA benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claim for increased disability ratings for his lumbosacral spine arises from an appeal of the initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed. Nonetheless, the Veteran was provided a notice in April 2005 as a part of the Benefits Delivery at Discharge program. The ROs sent letters in February 2006, March 2006, and February 2009 that provided information as to what evidence was required to substantiate the claim for an increased initial rating and explained the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and that evidence was needed to establish a disability rating and effective date and provided the detailed criteria for rating the lumbar spine. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Private treatment records were submitted by the Veteran and associated with the claims file. VA outpatient treatment records through January 2012 were obtained and associated with the claims file. The Veteran underwent VA examinations in May 2005, January 2006, March 2009, October 2010, February 2011, and January 2012. One examination did not include measurements of spinal motion, and the Veteran reported that the examiner in March 2009 did not use a required instrument during the examination. The Board concludes that the remainder of the clinical comments in these examinations and other examinations that did include proper measurements are adequate to evaluate the Veteran's service-connected lumbar spine disability as they include an interview with the Veteran, an accurate summary of the history, imaging studies, and a clinical examination that addressed the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's rating claim. The Board further finds that, since the last VA examination in January 2012, there is no credible lay or medical evidence suggesting an increased severity of symptoms to the extent that a higher rating may be warranted. Thus, there is no duty to provide further medical examination on this claim. See VAOPGCPREC 11-95 (Apr. 7, 1995). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's STRs, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a June 2011 before the undersigned. After that hearing, the Veteran submitted additional evidence identified as potentially relevant to his appeal. With respect to the claims being decided on appeal, the Board finds that all relevant VA records have been obtained, and that there are no outstanding requests to obtain any private treatment records for which the Veteran has identified and authorized VA to obtain on his behalf. Treatment records contain information that the Veteran is employed full-time, and the Board is unaware of any relevant records in the possession of the Social Security Administration. The Veterans Law Judge (VLJ) who chairs a hearing must fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the hearing in June 2011, the undersigned Acting VLJ spent considerable time speaking to the Veteran regarding the types of evidence and/or information capable of substantiating his claim. As a result of this discussion, the Veteran in fact submitted additional treatment records. The Board also requested additional examination to evaluate the nature and etiology of his lower extremity complaints. As such, the Board finds that it has fully complied with the Bryant requirements. To the extent there are any deficiencies, they were cured with further evidentiary development by the Board. Finally, the Board remanded this case in December 2011 for further evidentiary development. In response, the RO has updated the Veteran's VA clinic records, obtained an adequate VA examination report and readjudicated the claim. Thus, the Board finds RO compliance with prior Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims being decided. 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. Analysis The Veteran served as a U.S Air Force air cargo handler, training administrator, and contracting officer, retiring at the rank of Major. He contends that his lumbar spine disability is more severe than is contemplated by the initial rating. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Consideration is given to the potential application of the various provisions of 38 C.F.R. § Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Since the Veteran timely appealed the rating initially assigned for his disability, the Board must consider entitlement to "staged" ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca, supra. Although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (quoting 38 C.F.R. § 4.40). Lumbosacral strain and degenerative arthritis of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine. With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the Formula provides for ratings as follows. A 20 percent rating is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion is not greater than 120 degrees, or there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, revered lordosis, or abnormal kyphosis. A 40 percent rating is warranted when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Associated objective neurologic abnormalities are evaluated separately. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Diagnostic Codes 5237, 5242, Note 1. Normal ranges of motion for the lumbar spine are 90 degrees flexion, and 30 degrees extension, lateral flexion, and rotation. 38 C.F.R. § 4.71a, Plate V. Intervertebral disc syndrome (IVDS) permits evaluation under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5242, 5243. An incapacitating episode is a period of acute signs and symptoms due to IVDS requiring bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Formula for Rating IVDS. A 20 percent rating contemplates incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243, Formula for Rating IVDS. A higher 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Id. The RO received the Veteran's claim for service connection for back conditions in April 2005 under the Benefits Delivery at Discharge program while the Veteran was on active duty. In May 2005, a VA Advanced Practice Registered Nurse (APRN) noted the Veteran's reports of the onset of low back pain in 1983 while lifting heavy objects as an air cargo handler and that he sustained back injuries in a 1993 motor vehicle accident. The Veteran reported that he experienced back stiffness after prolonged sitting, was unable to stand more than 30 minutes, and was unable to walk more than one and one half miles. He denied any radiating pain or leg numbness. On examination, the APRN noted a positive straight leg lift test but no local tenderness, scoliosis, or lordosis. The APRN noted limitation in forward bending and extension but no limitations in other directions. There were no recorded goinometer measurements. The APRN diagnosed a musculoligamentous condition of the thoracolumbar spine. In an addendum two days later, the APRN noted that X-rays of the thoracic spine showed minimum dextroscoliosis of the spine but no fractures or abnormalities. The image evaluation was an "[e]ssentially unremarkable thoracic spine." In August 2005, a VA physician noted the same history of back strain and injury. The Veteran additionally reported the regular use of muscle relaxant and over-the- counter anti-inflammatory medications. He reported frequent muscle spasms and exacerbating episodes four times in six months lasting up to seven days. Although he described the episodes as "incapacitating," he reported that he was able to continue to work with the use of medication. He denied any neurological complications. The physician noted no point tenderness or abnormal curvature. Range of motion was 90 degrees flexion, 20 degrees extension, 20 degrees bidirectional lateral flexion, and 30 degrees bidirectional rotation. On repetition, there was an additional loss of function with flexion reduced to 60 degrees. The combined range of motion after repetition was 180 degrees. There was no further loss of function on repetitive use and no loss of sensation or muscle strength of the lower extremities. X-rays showed no degenerative changes or significant osseous abnormalities. The physician diagnosed lumbosacral muscle strain with a mild disability from pain with no significant loss of function. In March 2006, a private orthopedic physician noted the Veteran's reports of worsening low back pain that affected sleep and required the use of a back support while sitting. The physician did not measure the range of motion or comment on functional deficits but ordered a magnetic resonance image and suggested future epidural steroid injections. The Veteran did not identify or submit any additional records of follow-up care. In November 2006, a VA examiner assessed the lumbar spine disability, noting that the Veteran received several injections that provided only short term relief and the use of a back brace. The physician noted the Veteran's report of experiencing five flare-up episodes in the past year with the most recent flare-up that "put him at rest for one to two weeks....with a 75% reduction of function during that period." On examination, range of motion was 45 degrees flexion, 5 degrees extension, 15 degrees bidirectional lateral flexion, and 30 and 12 degrees right and left rotation. The combined range of motion was 122 degrees. The physician noted the Veteran's discomfort in getting on the examination table but noted no point tenderness or spasms. The physician diagnosed musculoskeletal strain with moderate functional impairment due to low back pain. In a statement received in July 2007, the Veteran described his forward flexion as being 30 degrees or less. An August 2007 VA clinic record found the Veteran's spine to be tender with a facial expression of pain with range of motion testing. No specific ranges of motion, however, were provided. In January 2008, he reported constant back pain made worse with ambulating stairs. In March 2009, a VA nurse practitioner (NP) performed an examination of the lumbar spine, knees, and ankles. The Veteran reported that he was unable to stand for more than five to six minutes or walk more than 50 feet. He estimated that he was 55 to 70 percent disabled because of the combined effects of the disabilities. He reported moderate, near constant low back pain with weekly flare-ups lasting two days and three incapacitating episodes in the past year each lasting three days. However, the Veteran also reported full time work and less than one week of lost time in the past 12 months. He reported somnolence when using prescription anti-inflammatory and muscle relaxant medication. On examination, the NP noted a normal posture with no abnormal curvature. There were no spasms, atrophy, guarding, tenderness, weakness or loss of sensation. Range of motion was 60 degrees flexion, 20 degrees extension, 20 and 24 degrees right and left lateral flexion, and 24 and 20 degrees right and left rotation with pain on motion but no additional loss of function on repetition. The NP referred to X-rays that showed possible minor facet arthropathy in the lower lumbar spine and diagnosed mild degenerative joint disease of the lumbar spine that imposed mild or no impairment of daily activities. The VA examiner further noted that the Veteran's service-connected back disability had significant effects on employability due to absenteeism, and mild effects on activities such as chores, exercise, sports and recreation. The examiner found no effects on activities such as shopping, traveling, feeding, bathing, dressing, toileting and grooming. In June 2009, the Veteran asserted that his lumbar spine flexion was much less than that recorded in the March examination and that a goniometer was not used. In October 2010, another VA NP noted a review of the claims file and performed a spinal examination. The Veteran reported continued moderate low back pain, stiffness, weakness, lower extremity numbness, the use of anti-inflammatory medications, and a transcutaneous electric stimulation unit with some relief. The Veteran reported that he lost less than one week of time from work in the past year. The NP noted no spinal curvatures, muscle spasms, atrophy, guarding, tenderness or loss of strength or sensation. Range of motion was 90 degrees flexion, 25 degrees extension, and 25 degrees bidirectional lateral flexion and rotation with pain on motion but no additional loss of function on repetition. The combined range of motion was 215 degrees. A lower extremity neurological examination was normal. X-rays showed mild degenerative arthrosis at sacroiliac joints of the lower lumbar spine. The NP concluded that pain would impose an effect of pain with daily activities but not on the Veteran's occupation. In February 2011, a VA physician performed another lumbar spine examination and noted the same symptoms and clinical observations. The Veteran reported no time lost from work in the past year. He endorsed a history of decreased motion, stiffness and constant pain exacerbated with increased exertion. He described his pain level as moderate. He denied fatigue, weakness, radiation of pain or incapacitating episodes of spine disease. He described being unable to walk more than a few yards due to both knee and spine disability. On examination, the Veteran demonstrated a normal posture with normal head position and symmetry of appearance. His gait was normal. There were no abnormal spinal curvatures or ankylosis. There was pain on with motion and tenderness of the thoracolumbar sacrospinalis bilaterally, but no spasm, atrophy, guarding or weakness. Range of motion was 61 degrees flexion, 16 degrees extension, 19 and 22 degrees right and left lateral flexion, and 21 and 20 degrees right and left rotation with pain on motion but no additional loss of function on repetition. The combined range of motion was 159 degrees. The physician referred to the October 2010 X-rays and also diagnosed mild sacroiliac degenerative arthrosis that imposed increased lumbar area pain with moderate lifting, pulling, and pushing tasks. During the June 2011 Board hearing, the Veteran stated that he had missed eight days of work in the past six months because of low back symptoms and the need to seek medical care. He stated that he experienced increasing tingling and numbness of the legs and drowsiness at work caused by the muscle relaxant medication. In July 2011, the Veteran was examined at a private family medicine clinic. The examiner noted the Veteran's reports of moderate but improving back pain but with radiating pain, tingling, and numbness of the lower extremities. He experienced lower leg problems 2 to 3 times per week which lasted 1 to 2 hours and then faded. The Veteran denied any bowel or bladder deficits. His symptoms were triggered changing positions, stepping wrongly, or other similar back motions. The examiner noted that the Veteran was limping and artificially fixing the position of his back during gait. A clinical neurologic examination showed normal motor function, and reflexes. The examiner diagnosed "Chronic back pain with some neurologic findings..." A July 2011 VA clinic record also noted the Veteran's complaint of low back pain (LBP) with radiation down both legs. Examination was significant for straight leg raise (SLR) test positive at 40 degrees on the right. The examiner provided an assessment of sciatica. In December 2011, the Board remanded the claim to obtain VA outpatient treatment records since July 2011 and another VA examination with attention to the neurologic manifestations. Additional VA outpatient treatment records through July 2012 were obtained and considered by the RO in a July 2012 supplemental statement of the case. In January 2012, a VA physician noted a review of the claims file and the Veteran's reports of all day back pain five to seven days per week exacerbated by prolonged sitting and any lifting. He reported flare-up episodes once per month lasting three days which required missing work. The flare-ups resolved with rest and medication. Range of motion was 50 degrees flexion, 20 degrees extension, 20 degrees bidirectional lateral flexion and rotation limited by pain, less movement than normal, weakened movement, and excess fatigability but no additional loss of function on repetition. The combined range of motion was 150 degrees. The paravertebral muscles were tender to palpation, but there was no guarding or muscle spasm. The physician noted a normal gait with no use of support devices. The physician noted tenderness but no muscle spasms, atrophy, or loss of strength of the lower extremities. The Veteran endorsed mild intermittent pain, dysesthesias and numbness of both lower extremities. Reflexes were normal, but there was some loss of sensation in the toes and mild radiating pain to the lower extremities. The physician cited an imaging study for his conclusion that there was no diagnosed arthritis of the spine, but the narrative of the imaging report is the same as that noted for the VA X-ray in 2005. The physician also noted that the Veteran was not diagnosed with IVDS. Although the physician noted mild symptoms of numbness and parathesias in the lower extremities in one part of the report, he noted normal function of all specific nerve systems of the lower extremities. He explained his observations as follows: Please note that he has pain/dysthesias which radiate from the back to the legs. This is not the same as radiculopathy. Please note that the distribution of stated symptoms and locations do not match dermatomal patterns...He also has negative straight bilateral straight (sic) leg raises. Based on the objective data review, he does not have radiculopathy. This is based on the fact that there is no evidence of disc compression of the spinal cord/neural foramina and the distribution of the signs and symptoms from the examination. There is no formal peripheral nerve condition. Overall, the examiner assessed the Veteran's thoracolumbar spine disability as impacting his ability to work due to increased absenteeism due to back pain. As the examiner noted a review of the history, interviewed the Veteran, and performed a detailed clinical examination with observations and conclusions addressing the elements of the rating criteria, the Board concludes that the examination is adequate and that there has been substantial compliance with the remand instructions. The Board concludes that a rating in excess of 20 percent for lumbosacral strain with sacroiliac disorder is not warranted at any time during the period covered by this appeal. First, the Board concludes that a rating under the General Rating Formula for Diseases and Injuries of the Spine in excess of 20 percent is not warranted because all measurements of lumbar spine flexion by goniometer are greater than 30 degrees with no ankylosis. Examiners noted flexion from 45 to 90 degrees with some range of motion in all directions. The examiners found no evidence of ankylosis. To the extent that the Veteran experiences radiating pain, this pain is contemplated in the rating criteria. There is some evidence for and against the presence of degenerative changes of the spine rather than simple recurrent muscle strain. Nevertheless, the General Rating Formula contemplates both diagnoses. Here, the Veteran primarily describes decreased function during flare-ups of disability. For example, he describes the need for rest during these flare-ups at which time he experiences a "75% reduction of function." He has self-described his limitation of motion as being less than 30 degrees of flexion. He also experiences increased pain and stiffness after prolonged use. He appears to report varying degrees of frequency and duration of these flare-up episodes - 4 times in six months lasting up to 7 days (August 2005), less than one week of lost time in last year (October 2010), no lost time from work (February 2011), 8 lost days of work in past 6 months (June 2011), and once per month lasting three days and required lost work time (January 2012). The Veteran's report of low back pain exacerbated by activity is credible and consistent with the clinical findings, such as the descriptions of muscle tenderness and a facial expression of pain with range of motion testing. However, the extent of functional impairment described by the Veteran does conflict with the examination findings. For example, the Veteran reports forward flexion of 30 degrees or less and requested a new examination based on his recollection that a goniometer was not used. At this point, the record contains forward flexion findings of 90 degrees (August 2005), 45 degrees (November 2006), 60 degrees (March 2009), 90 degrees (October 2010), 61 degrees (February 2011) and 50 degrees (January 2012). These examiners did find evidence of functional impairment of pain, less movement than normal, weakened movement, and excess fatigability but no additional loss of motion on repetition. Overall, while the Veteran's complaints of functional impairment are credible, the Board finds that the clinical findings by VA examiners throughout the appeal period of forward flexion of 45 degrees or greater even when considering functional impairment on use holds substantially more probative value than the Veteran's self-descriptions. In this respect, the VA examiners in October 2010, February 2011 and January 2012 measured motion with use of a goniometer which is more accurate than the Veteran's self-description of 30 degrees or less. Additionally, while it is alleged VA clinicians did not use a goniometer in prior examinations, the Board nonetheless notes that their experience with range of motion testing techniques would still provide a relatively reliable measurement of motion. In short, the Veteran's motion range from 45 to 90 degrees of forward flexion falls well short of approximating the criteria for forward flexion limited to 30 degrees at any point during this appeal period. Regarding flare-up episodes, the Veteran appears to have reported up to 28 days of lost work in a six-month period in August 2005, one week for the year 2010, 8 lost days for 2011 and no lost days of work in January 2012. The associated private and VA clinic records reflect no episodes of physician ordered rest. The Veteran continues to work full time at an administrative occupation. The Veteran's functional impairments have been described as a "mild" disability (May 2005), "moderate" functional impairment (November 2006), having "mild" effects on some daily activities (March 2009), pain with daily activities (October 2010), increased lumbar area pain with moderate lifting, pulling, and pushing tasks (February 2011) and impacting his ability to work due to increased absenteeism due to back pain (January 2012). Further, the Veteran has reported that the type of anti-inflammatory and muscle relaxant medications he uses cause of loss of concentration and excessive drowsiness at work. Taking into account all of these factors, the Board finds that the Veteran does not meet, or more closely approximate, the criteria for a rating higher than 20 percent for his service-connected thoracolumbar spine disability. As held above, his thoracolumbar spine flexion falls well short of the criteria for a 40 percent rating even when considering functional impairment on use due to factors such as pain, less movement than normal, weakened movement, and excess fatigability. His 20 percent rating contemplates exacerbations and loss of work time proportionate to grades in disability - which overall in this case have been clinically described as mild to moderate in degree from a functional standpoint. See 38 C.F.R. § 4.1. Overall, the Board finds that these factors do not warrant a higher rating under the Rating for Diseases and Injuries of the Spine, or a separate rating based upon functional impairment on use under 38 C.F.R. §§ 4.40 and 4.45. The Board further notes that the Veteran is also not entitled to a higher rating based upon consideration of the Formula for Rating IVDS. First, the VA physician in January 2012 concluded that the Veteran did not have IVDS and there is no medical opinion to the contrary. To the extent that the Veteran argues otherwise, the Board places greater probative value to the opinion of the January 2012 VA examiner who has greater expertise and training than the Veteran in identifying and evaluating IVDS. Second, even if the Formula for Rating IVDS applied to this case, the criteria for the next higher 40 percent rating have not been met. The regulation specifically defines an incapacitating episode as a period of acute signs and symptoms due to IVDS requiring bed rest prescribed by a physician and treatment by a physician. There is no lay or medical evidence that the Veteran had physician-prescribed bed rest for a total duration of at least 4 weeks for any 12-month period. Thus, the criteria for a 40 percent rating would also not be met. Regarding separate neurologic complications, there is no lay or medical evidence of bowel or bladder dysfunction. The first lay report and medical assessment of tingling and numbness of the lower extremities was in the transcript of the Board hearing in June 2011 and in the record of private and VA care in July 2011. The Board remanded the claim, in part, to obtain a medical assessment of the reported symptoms. The Board places greatest probative weight on the conclusions of the VA physician in January 2012 who reviewed the entire history and performed a full clinical neurologic examination as reflected in the examination report. He concluded that there was no current peripheral neurologic disorder because the spinal disease was without nerve root involvement and the fact that the Veteran's description of symptoms does not match dermatomal patterns. The Board finds that the January 2012 VA examiner's opinion substantially outweighs the July 2011 private examiner statement of chronic back pain with 'some neurologic findings" and the assessment of "sciatica" in the VA clinic setting. In this respect, the private and VA clinicians appeared to provide a cursory examination with very little specific clinic findings provided, and no rationale for the conclusion reached. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (noting that a probative medical opinion supports its conclusion with an analysis that the Board can consider and weigh against contrary opinions). On the other hand, the VA examiner provided a more comprehensive analysis and explained the specific reasons why a chronic neurologic disability was not found. Additionally, given the relative level of expertise and training, the Board also finds that the VA examiner's opinion greatly outweighs any opinion by the Veteran. The Board has also considered whether this case warrants referral to the Director, Compensation and Pension service for extraschedular consideration under 38 C.F.R. § 3.321(b). For extra-schedular consideration, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability; if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no extra-schedular referral is required. 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). In this case, the applicable rating criteria contemplate the limitation of motion and function including the Veteran's chronic back pain and radiating pain. Although he is unable to sit for prolonged periods of time or walk for long distances, he is able to work full time and perform all daily activities including operating a motor vehicle. The rating criteria do not directly address the effects of medication, but the rating schedule in general contemplates loss of working time and workplace impairment according to the several grades of percentages provided. The clinicians have described the Veteran's functional impairments to be mild to moderate in degree. For these reasons, the Board concludes that the rating criteria adequately contemplate the lumbar spine disability and that referral for extra-schedular consideration is not warranted. In sum, the Board finds that the Veteran's lumbosacral spine strain with sacroiliac disorder is manifested by limitation of thoracolumbar spine flexion greater than 30 degrees with no ankylosis or peripheral neurologic disease for the entire appeal period. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the Board must deny the claim. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial disability rating in excess of 20 percent for lumbosacral strain with sacroiliac disorder. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs