Citation Nr: 1331546 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 08-00 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a disability manifested as left side pain due to a lightning strike. 2. Entitlement to service connection for sleep disorder, to include sleep apnea, claimed as secondary to posttraumatic stress disorder (PTSD). 3. Entitlement to a rating in excess of 10 percent for chronic lumbosacral strain. 4. Entitlement to a rating in excess of 10 percent for chronic cervical strain. 5. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD H.J. Baucom, Counsel INTRODUCTION The Veteran had active service from May 1979 to January 1981, from May 1-3, 1998, and from January to May 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in October 2008, July 2009 and January 2010 of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In June 2012, a Board hearing was held at the RO before the undersigned, the transcript is of record. In January 2013, the Board remanded the claims for further development which has been completed. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the Virtual VA and VBMS system, to ensure a complete review of the evidence in this case. FINDINGS OF FACT 1. A disability manifested by left sided pain is not shown. 2. A sleep disorder was not shown in service and is not related to any disease or injury incurred in service, nor was it aggravated by a service-connected disability. 3. A low back disability is manifested by forward flexion of the thoracolumbar spine greater than 60 degrees with a combined range of motion greater than 120 degrees. There are no muscle spasms or guarding severe enough to result in an abnormal gait. There is no abnormal spinal contour. There are no objective findings of neurological abnormalities. 4. A neck disability is manifested by forward flexion greater than 30 degrees and combined range of motion of the cervical spine greater than 170 degrees. There are no muscle spasms or guarding severe enough to result in an abnormal gait. There is no abnormal spinal contour. There are no objective findings of neurological abnormalities. 5. The Veteran is currently service-connected for PTSD rated 50 percent disabling, migraine headaches rated 30 percent disabling, a back disability rated 10 percent disabling, and a neck disability rated at 10 percent disabling; the combined disability evaluation is 70 percent. 6. The Veteran's service-connected disabilities do not render him unable to obtain or retain substantially gainful employment. CONCLUSIONS OF LAW 1. A disability manifested as left side pain due to a lightning strike was not incurred in or aggravated by service; no left-sided pathology is currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2013). 2. A sleep disorder, to include sleep apnea secondary to PTSD, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2013). 3. The criteria for a rating in excess of 10 percent for chronic lumbosacral strain have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.10, 4.40, 4.45, 4.71(a), Diagnostic Code (DC) 5242 (2013). 4. The criteria for a rating in excess of 10 percent for chronic cervical strain have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.10, 4.40, 4.45, 4.71(a), DC 5237 (2013). 5. The criteria for entitlement to TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to his claims. In this decision, the Board has also considered the lay evidence as it pertains to the issues. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). "Competent medical evidence" means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to evaluating the medical evidence, generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Service Connection Claims Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). Service connection may be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In this case, none of the service connection claims on appeal are listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Similarly, none of the claims on appeal are listed in 38 C.F.R. §§ 3.307, 3.309(a); therefore, the one-year presumption does not apply. Service connection may also be established for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left-Sided Pain The Veteran contends that he has a left side disability due to being struck by lightning in service. There is no dispute that he was struck by lightning in service in May 1998. In fact, he is service-connected for disabilities related to the incident, to include PTSD, migraine headaches, chronic cervical strain and chronic lumbosacral strain. The Veteran describes his disability as chronic constant pain, radiating from the neck and back into his left upper and lower extremities. He stated that his pain makes it difficult to sleep and he takes prescription medication for his pain, naproxen. He has reported a history of lumbar radiculopathy. He has also reported pain and weakness in his left leg, for which he needs a cane to provide stability when he walks. VA clinical records note the Veteran's complaints of pain up and down his back and neck and going into his extremities. There is a notation of lumbar radiculopathy but only per his history, not based upon any medical evaluations. The clinical records do not contain a specific diagnosed disability related to his left side complaints. A January 2010 VA general examination addressed the Veteran's lightning strike residuals. He reported a history of being struck by lighting which entered through his left elbow and exiting through his left foot. He described pain involving the left side, particularly the elbow, back region, and left knee area. He reported no complaints of any numbness or paresthesias or loss of sensation at the time. He denied residual scarring but reported ongoing pain on daily basis for which he took Advil for as needed. He denied loss of strength or difficulty with standing or ambulation. He reported his pain is aggravated with prolonged activity. Physical examination found posture and gait to be normal and noted that he walked without the use of assistive devices. The examiner noted the Veteran's reports of back pain, headaches, and PTSD which are all disabilities for which he is already separately service connected. The examiner diagnosed lightning strike as described with residuals, as described, but no functional impairment. A separate disability of left-sided pain was not listed as a chronic residual. A December 2009 VA neurological examination found the Veteran's sensory assessment to be intact to all modalities including upper and lower extremities. He subjectively felt less sensation to pinprick on the left lower extremity; however, objectively no focal sensory loss was detected. He reported a history of pain in the upper arm joints, lower back pain and radicular pain, and neuropathy pain. A December 2009 VA spine examination also conducted neurological testing and physical examination and found that he did not have lumbar radiculopathy. A March 2013 VA spine examination found there to be only subjective complaints of cervical and lumbar radiculopathy but no objective findings for lumbar or cervical radiculopathy. Following multiple VA examinations, to include neurological and spine, a March 2013 addendum specifically addressed the Veteran's subjective symptoms of mild left lumbar radiculopathy for the last few years. The physician reported that a magnetic resonance imaging (MRI) scan of the lumbar spine showed mild L4-L5 paracentral disc herniation, and an electromyography (EMG) in March 2013 was negative for radiculopathy. The physician found there to be no objective focal motor or sensory deficit, and that service treatment records mention lumbar strain or radiculopathy symptoms but there are no clinical findings or objective findings related to lumbar radiculopathy. At the June 2012 Board hearing, the Veteran testified that he had pain, numbness, and weakness going up and down his whole left side ever since he was struck by lightning. He is competent to report symptoms that he experiences such pain, as he experiences it through his five senses; however, he is not competent to diagnose a medical disorder of lumbar radiculopathy because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). His opinion that he has a left side disability is outweighed by the competent medical opinion of multiple physicians who examined him, conducted testing and determined that he does not have lumbar radiculopathy or any other left side disability. As a general matter the Board must consider whether a veteran's particular disability is the type of disability for which lay evidence is competent. Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, diagnosing a left side pain disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. The Veteran is service-connected for disabilities related to the lightning strike: headaches, chronic cervical strain, chronic lumbosacral strain, and PTSD. Considering the evidence above, the Board finds that there is no diagnosed left side disability. Despite multiple examinations, a disability manifested by left sided pain has not been found. At best, there is competent lay evidence of pain, without any showing of actual functional impairment. Pain alone, without any functional impairment or underlying diagnosis, is not a service connectable disability. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part, dismissed in part by Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect some aspect of 'the normal working movements of the body such as 'excursion, strength, speed, coordination, and endurance,' in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. In the absence of proof of a present disability there can be no valid claim. Brammer v. Brown, 3 Vet. App. 223 (1992). Accordingly the appeal is denied. Sleep Disorder, to Include Sleep Apnea The Veteran contends that he has a sleep disorder, to include sleep apnea, secondary to his service-connected disabilities, specifically PTSD. A March 2009 VA neurology examination evaluated the Veteran, diagnosed a sleep disorder and ordered a routine sleep study. A June 2009 sleep disorder consult with overnight sleep study found that he had mild obstructive sleep apnea-hypopnea syndrome, excessive daytime sleepiness and insomnia. He complained of snoring, poor sleep with sleep maintenance insomnia and early morning awakening, daytime sleepiness, and chronic pain since being hit by lightening. In July 2009, the same VA examiner reviewed the sleep study which diagnosed mild obstructive sleep apnea and insomnia and reported that sleep apnea is not caused by PTSD, and not caused by being struck by lightning in service, that there was no casual relationship between sleep apnea and PTSD, and lightning trauma did not cause sleep apnea. As the opinion did not specifically address whether PTSD aggravated the Veteran's sleep disorder, a additional VA examinations were conducted in March and April 2013. In March 2013, the examiner reported that sleep apnea was intermittent upper airway obstruction pathology and had no relationship with PTSD, which is predominantly a psychiatric diagnosis and there was no causal relationship between the two. The examiner provided the opinion that sleep apnea was not aggravated by PTSD. The examiner also explained that the Veteran was first diagnosed with sleep apnea in June 2009 with no findings of sleep apnea in service. At the April 2013 VA examination, the Veteran reported a history of intermittent loud snoring and night with some apnoeic episodes and daytime sleepiness. He also reported a history of back pain, headache, pain in upper arm, and anxiety disorder for which he took prescription medication. He had been prescribed a CPAP machine and reported responding to treatment. The examiner provided an opinion that there was no relationship between sleep apnea and PTSD explaining that PTSD was predominantly a psychiatric condition and sleep apnea was usually secondary to intermittent upper airway obstructive pathology not caused or aggravated by PTSD. The examiner also noted that there were no specific symptoms related to sleep apnea noted during service or in post service discharge notes and it was less likely than not the current sleep apnea was related or caused by service. In sum, there is no evidence of a sleep disorder in service, nor does the Veteran contend as such. He first reported experiencing a sleep disorder in his March 2005 claim. He contends that he has a sleep disorder (difficulty sleeping, insomnia, sleep apnea) which was caused by his service-connected disabilities, due to PTSD and pain. The Board notes that the Veteran is currently-assigned a 50 percent rating for his service-connected PTSD. The rating criteria for PTSD include consideration of sleep problems. Specifically the 30 percent rating criteria identifies "chronic sleep impairment" as a symptom of PTSD for which the Veteran is already being compensated. 38 C.F.R. § 4.130. The Rating Schedule generally prohibits pyramiding, i.e., evaluating the same disability under different diagnostic codes. 38 C.F.R. § 4.14. As sleep disturbances, to include insomnia, are already evaluated under the criteria for PTSD, they will not be separately evaluated. As such, to the extent that he claims sleep problems due to PTSD, the is already being compensated. Separately, the competent evidence of record demonstrates that the Veteran's sleep apnea has not been caused or aggravated by his PTSD. The medical opinions of record explain that sleep apnea is caused by an intermittent upper airway obstructive pathology, a physical condition, and that sleep apnea is not caused or aggravated by PTSD. These opinions weigh against the claim. The Veteran is competent to report what he experiences, such as sleep disturbances and pain, as he experiences them through his five senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to provide a medical opinion that his service-connected PTSD has caused his sleep apnea because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Therefore his opinion has little, if any, probative value. The medical opinions of record have more probative weight than his lay assertions. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether PTSD, or any other disability, caused or aggravated sleep apnea falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The weight of the competent evidence is against the claim; there is no doubt to be resolved; service connection for sleep disorder, to include sleep apnea, is not warranted and the appeal is denied. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. While a veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Disabilities of the spine, such as a low back disability and neck disability, are to be rated pursuant to 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. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is assigned when forward flexion of the thoracolumbar spine is 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 is not greater than 120 degrees; or, the combined range of motion of the cervical spine is not greater than 170 degrees; or, there is 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 rating is assigned when forward flexion of the cervical spine 15 degrees or less; or, there is favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned when there is unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine is 30 degrees or less; or, there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 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 1 under the General Rating Formula provides for separate evaluations for any associated objective neurologic abnormalities. Note 5: For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 under the General Rating formula dictates to separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Intervertebral disc syndrome (DC 5243) may be rated under the General Rating Formula above, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever provides for the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. A 20 percent rating is assigned for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks during the past 12 months. A 60 percent rating is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under DC 5243, an incapacitating episode is 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. At the VA examinations, the Veteran consistently denied having any incapacitating episodes and such evaluation under DC 5243 is not applicable. At the June 2012 Board hearing, the Veteran reported difficulty bending, and sitting down and getting up. He reported that he could not lie on his back, and that the pain caused him to toss and turn at night. He requested a stiffer chair in the hearing room. He testified that he could only bend a little and that he did not do too much bending, such as bending over to pick up stuff or put on his shoes. He reported having pain shooting up and down his back and neck. The Board notes the Veteran appeared able to turn his neck. Multiple VA examinations were conducted during the period on appeal. In a December 2009 VA orthopedic spine examination, the Veteran reported constant pain and discomfort in his neck and lower back with some numbness and shooting pain down the left leg. He reported no problem with repetitive use, no flare ups and no incapacitating episodes. He had a slightly antalgic gait which the examiner found was due to his non service connected left knee. Upon physical examination the examiner found there to be symptom magnification in the physical examination and that the symptoms were not consistent with the Veteran's report. As to the lumbar spine, there was decreased range of motion in all planes. He flexed to 60 degrees, extended to 20 degrees, side bent to the right 15 degrees, side bent to the left 20 degrees, rotated to the right 15 degrees and rotated to the left 20 degrees. As to the cervical spine, there were complaints of pain on all range of motion. The Veteran rotated to the right 60 degrees, rotated to the left 50 degrees, extended 30 degrees, flexed 25 degrees, side bend to the right 25 degrees, and side bend to the left 30 degrees. After repetitive motion of the cervical and lumbar spine, there was no additional loss of joint function due to pain, fatigue or lack of endurance. The examiner found there to be no radiculopathy. In December 2009, the Veteran underwent a VA neurologic examination which included evaluation of the spine. On examination of the back, there was no paraspinal muscle spasm. There was tenderness noted on the right L4-L5, L5-S1 paravertebral muscle. Range of motion was slightly decrease in forward and lateral flexion and slightly decreased in lateral rotation. Straight leg raising test was up to 60 degrees bilaterally. In a January 2010 VA general examination, the Veteran described low back pain which started after being struck by lightning in service. Since then he has describe low back pain which is exacerbated with prolonged sitting and standing. He stated that the left side of his body is more involved. He takes Advil as needed for pain control. The notes refer to the orthopedic examination for additional details. In February 2012 a general VA examination was conducted, noting the back and neck conditions. The chart was reviewed and the Veteran examined. The Veteran's main complaints were related to his headaches, mental health issues and back problems. He reported not taking any medication other than OTC pain medication. In a February 2012 VA examination of the cervical spine and back, the Veteran appeared using a cane for support. He reported constant pain in the neck and back in all activities. He reported pain radiating down left arm and leg. He reported that his pain limits his ability to stand, walk, lift, do work around the house. As to any medical treatment, he reported that he has not seen a doctor about his condition, no pain management, no recent physical therapy, no injections, and no history of any surgeries. He also reported no bowel or bladder changes, no incapacitating episodes or flare ups, and no problem with repetitive use. Upon physical examination, the examiner again noted symptom magnification and reported "He is trying to deceive me. He does not give me full effort." As to the lumbar spine, he refused to demonstrate range of motion and overreacted to superficial palpation. The examiner noted positive Waddell's sign. He refused to flex and flexed to 10 degrees, extended 10 degrees, side bent to the right 5 degrees, side bent to the left 10 degrees, rotate to the right 10 degrees and rotate left 5 degrees. There were subjective complaints of pain on all ranges of motion but the examiner found no objective signs of pain, no atrophy, no scoliosis, and no deformity. As to the cervical spine, the VA examiner found no muscle spasms, no scoliosis, and no deformities. The Veteran again refused to demonstrate full range of motion. He rotated to the right 50 degrees, to the left 40 degrees, extension to 10 degrees, side bend to the right 20 degrees, and side bend to the left 10 degrees. There were subjective complaints of pain on all ranges of motion but no objective signs of pain. The examiner again noted symptom magnification and his opinion was that the Veteran was trying to deceive him as to his symptoms. In a March 2013 VA examination of the cervical spine and back, the Veteran reported increasing neck and lower back pain daily, constantly. He reported that it radiated down his left arm and leg and interfered with all daily activity. He stated he was weak and had loss of bowel and bladder. He reported that the pain was aggravated with walking, standing, sitting and interfered with all activities. He reported using a straight cane because he felt unstable. There was no interference with his job as he had not worked since 1998. He was independent in all activities of daily living (ADL). He reported no physical therapy, no recent injections, no surgeries, no incapacitating episodes or flare-ups and no hospitalizations. He reported constant pain 24 hrs a day 7 days a week. Neurological testing was also conducted. The Veteran's motor strength was waxing and waning. The examiner found he was not giving full effort but when he did give full effort, it is 5/5. Straight leg raising test was negative. Muscle tone was normal. Babinski's was negative. Hoffmann's sign was negative. Sensation intact to light tough in both upper and lower extremities. Motor strength of upper and lower extremities was 5/5. He gave waxing and waning type of nonanatomical disruption but 5/5 motor strength. No muscle spasms. No scoliosis. No atrophy of the cervical and lumbar spine. The VA examiner noted "[o]nce again, symptom magnification is noted" and the Veteran overreacts to sham testing and superficial palpation. As to the lumbar spine, he refused to demonstrate range of motion. He flexed to 20 degrees, extended to 10 degrees, side bent to the right 25 degrees, side bent left 15 degrees, rotated right 10 degrees and rotated left 10 degrees. There were no objective signs of pain. As to the cervical spine, the Veteran refused to demonstrate full range of motion, stating he was in too much pain although the examiner found there to be no objective signs of pain. He flexed 20 degrees, extended 25 degrees, side bend right 20 degrees, side bend left 15 degrees, rotated right 10 degrees and rotated left 20 degrees. After repetitive motion of the cervical and lumbar spine, there was no additional loss of joint function due to pain, fatigue or lack of endurance. The examiner found there to be no objective findings of cervical or lumbar radiculopathy, only subjective complaints. VA clinical treatment records show that the Veteran has not been seeking specific treatment for his back and neck pain. He reported at examinations, discussed above, that he had not seen a doctor for his condition, or had physical therapy or injections or any other treatment for his condition aside from over the counter medication. The Board does note that at mental health treatment appointments, and primary care visits the Veteran consistently reported having physical pain related to his back and neck, and that the pain interfered with his sleep. For example in November 2009, he reported arthralgia (joint pain) and thoracic and lumbar spasms; however, the debilitating level of pain he has reported at VA examinations is not the same he has reported elsewhere. Specifically at a March 2009 mental health consult, he reported that the level of pain was acceptable to him and that the pain did not significantly interfere with activities of daily living. The psychiatrist recommended treatment but the Veteran refused any treatment at that time. He was instructed to discuss with provider if his pain become unmanageable or interfered with activities of daily living. He reported that he had not been given pain medication but had been prescribed medications to slow the brain down. Based on the evidence above, the Veteran is competent to report his pain symptomatology, as it is something he can experience through his five senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board finds his reports of debilitating pain to such a level of severity that he cannot move as reported at the three VA spine examinations identified above to be not credible for the following reasons: (1) the VA examiner who evaluated the Veteran opined that he was exaggerating his symptoms, (2) the Veteran's lay statements of severe debilitating pain were made in the context of increased rating claims, and (3) that despite the claimed debilitating pain and inability to move the Veteran is not seeking any treatment whatsoever for his conditions. The VA examiner found on three separate occasions - December 2009, February 2012 and March 2013 - that the Veteran was magnifying his symptoms as to the level of impairment his back and neck pain cause. This same examiner conducted a VA spine examination in October 2007 (not during the time period on appeal) but did not find that the Veteran was magnifying his symptoms. The examiner's opinions are of greater probative value as they are supported by the detailed medical findings made at the examinations. In December 2009, the examiner found that the symptoms reported were not consistent with the Veteran's evaluation, despite pain in all ranges of motion he was still able to move. In February 2012, the examiner found that as to the lumbar spine the Veteran overreacted to superficial palpation, and although there were subjective complaints of pain, there were no objective signs of pain, no atrophy, no scoliosis, and no deformity. As to the cervical spine, there were subjective complaints of pain on all ranges of motion but no objective signs of pain. In March 2013, the Veteran refused to demonstrate full range of motion, claiming he was in too much pain although there were no objective signs of pain. The examiner noted that the Veteran overreacted to sham testing and superficial palpation, there were no objective signs of pain, no muscle spasms, no scoliosis, no atrophy, and that the Veteran gives waxing and waning type disruption but there was 5/5 motor strength. As a medical doctor, the examiner is well qualified to provide objective observations and conduct full medical evaluations. There is no reason for the Board to find the examiner's opinion of symptom magnification, supported by his findings of no objective signs of pain, to be not credible. The Veteran's general lay statements as to the severity and debilitating effect of his pain were made in the context of examinations and hearings conducted for an increase in disability rating. At the December 2009 neurological examination his range of motion was only slightly decrease in forward and lateral flexion and slightly decreased in lateral rotation; yet at the December 2009 spine examination, for increased rating, the range of motion findings were of decreased capacity, and the examiner opined there was symptom magnification. At the June 2012 Board hearing, the Veteran testified that his pain was constant and he could not bend at all but the Board makes the observation that he was able to move his neck without any apparent limitation. The Veteran's lay assertions as to severity of impairment made at the VA examinations for increased ratings are less credible as compared to his statements made in the context of treatment for other disabilities. See Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). The Veteran is not seeking any treatment for his back and neck pain despite his statements at VA examinations that his pain is to the level of severity that he cannot move. At the VA spine examinations, he reports constant debilitating pain but reports only taking over the counter medication and that he has not had physical therapy, or injections, or surgery, or reports not seeking treatment for his back and neck. Conversely, in March 2009, his told his mental health provider that his pain was acceptable and did not interfere with his activities of daily living. It was recommended that he seek treatment but he declined. The Board finds the credibility of the Veteran's lay statements of debilitating pain to be undermined by his failure to seek any type of treatment to alleviate the pain. In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self- interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Board finds the VA examiner's opinion, supported by objective findings, that the Veteran was exaggerating his symptomatology to have greater probative weight than the Veteran's non-credible statements of debilitating pain. The Board finds the December 2009 VA examination to be the most accurate examination on which to rate the Veteran's back and neck disabilities, and that the February 2012 and January 2013 examinations are inadequate for rating purposes as the results are inaccurate due to symptom magnification. Currently, the low back disability is rated as 10 percent disabling. In order for a higher 20 percent rating to be assigned there must be forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. Although forward flexion was found to be 60 degrees with no additional loss of function after repetitive use at the December 2009 VA spine examination, the examiner found there was symptom magnification at this examination. The Board finds that the accurate measurement is greater than 60 degrees forward flexion. The finding of forward flexion of 60 degrees is further contradicted by the December 2009 VA neurological examination which found only slightly decreased flexion. Normal forward flexion is 90 degrees. The combined range of motion was greater than 120 degrees. No muscle spasms or guarding were found to result in an abnormal gait or spinal contour. The Veteran's antalgic gait was noted to be due to a non service connected left knee disability. There is no evidence of ankylosis, favorable or unfavorable, of the thoracolumbar spine. As such, a rating in excess of 10 percent for a low back disability is not warranted. Currently the neck disability is rated as 10 percent disabling. In order for a higher 20 percent rating to be assigned there must be forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or combined range of motion of the cervical spine not greater than 170 degrees. Although forward flexion was found to be 30 degrees, with no additional loss of function after repetitive use, at the December 2009 VA spine examination, the examiner found there was symptom magnification at this examination. The Board finds that the measurement of 30 degrees includes the Veteran's symptom magnification, meaning the measurement is in fact greater than 30 degrees and does not meet the criteria for "not greater than 30 degrees" required for the next higher rating. There is no evidence of ankylosis, favorable or unfavorable, of the cervical spine. As such, a rating in excess of 10 percent for a neck disability is not warranted. The Board has also considered whether the Veteran is entitled to a separate and compensable rating for any neurological disability. He has reported a history of lumbar radiculopathy, and a private September 2012 MRI of the lumbar spine noted a clinical history of lumbar radiculopathy; however, despite multiple examinations, both orthopedic and neurological, there are no objective findings of radiculopathy. In December 2009 the examiner opined "I do not feel that the patient has radiculopathy." At the January 2010 examination, the Veteran did not complain of any numbness or paresthesias or loss of sensation at the time. A March 2013 neurological evaluation found subjective complaints of radiculopathy, but no objective findings. In conjunction with the examination an EMG was done which was negative for radiculopathy. There was no objective focal motor or sensory deficit. There were no clinical findings and no objective findings related to lumbar radiculopathy. As there is no diagnosed lumbar radiculopathy or other neurological disability related to the back or neck disability, a separate compensable rating for such is not warranted. TDIU The Veteran alleges that he is not employable due to his PTSD, headaches, back disability and neck disability and is therefore entitled to TDIU. Total disability ratings for compensation may be assigned where the schedular rating is less than total, and the disabled person is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16(a). There is no requirement that employment be in a certain field or provide a certain standard of living or income level beyond the poverty level. Basic eligibility is established where there is one disability rated 60 percent or more, or multiple disabilities rated at least a combined 70 percent, with one disability rated at least 40 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran has four disabilities: PTSD rated as 50 percent, headaches rated as 30 percent, back disability rated as 10 percent, and a neck disability rated at 10 percent. As he has multiple disabilities rated with a combined rating of 70 percent and one disability at least 40 percent therefore the schedular eligibility requirements under 38 C.F.R. § 4.16(a) are met. Extraschedular consideration under 38 C.F.R. § 4.16(b), for veterans found to be unemployable but not meeting the schedular thresholds, is not required. The question is whether the Veteran's service-connected PTSD, headaches, back disability and neck disability render him unable to obtain or retain substantially gainful employment. Factors to be considered include but are not limited to employment history, educational achievement, and vocational attainment. Age is not a factor to be considered. 38 C.F.R. § 4.16. The Veteran submitted a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, in which he reported that he had been disabled from work since 1999 and listed employment history of cook from November 1998 to May 1999 and prior to that a manager from September 1995 to December 1997. At the June 2012 hearing, the Veteran testified that he stopped working in 1998 due to being struck by lightning in service. He testified that he tried to work one job but he could not stand so he did not keep working. At the March 2008 RO hearing, he reported that his work consisted of doing odds and ends around his church, such as cleaning. He is receiving Social Security disability based on impairments of migraine headaches, degenerative joint disease of the left knee, sleep apnea, depressive disorders and PTSD. Multiple VA opinions have been provided as to the affect of the Veteran's service connected disabilities on his employability. Specifically, an October 2007 VA examination for migraine headaches noted that although they were chronic, at work he could continue his work after taking some rest and medication. A November 2009 VA psychiatric examiner opined that the Veteran's psychiatric problems did not prevent him from being employed. In December 2009, the VA spine examiner opined that there was no impairment for the Veteran as to physical or sedentary employment and that it was common to have cervical sprain/strain and lumbar sprain/strain with lumbar degenerative disc disease and perform a physical and sedentary type of labor. The December 2009 neurological examiner found that migraine headaches would not interfere with employment, depending on what kind of employment the Veteran would be doing. The examiner reported that there were no incapacitating effects from the headaches. At the examination, the Veteran reported that he was not able to continue his job in security of other jobs that he tried because his legs swelled up and he has arthritis in the leg and pain in the lower back. A February 2012 general disability benefits questionnaire (DBQ) noted to see other DBQs (included below) regarding employability, as in her evaluation there were no significant functional deficits which would preclude employment. A February 2012 psychiatric examiner reported that the Veteran's ability to work was deferred to his medical examiners as there were no psychiatric reasons for an inability to work. At a February 2012 headache examination, the examiner opined that the Veteran had other issues which were troubling, but migraines are not the cause of his unemployability. At the February 2012 back examination the examiner opined that there was no impairment as far as physical and sedentary type of work due to the fact that there were positive Waddell's signs. The examiner found no objective signs of cervical and lumbar pathology which would prevent him from doing gainful employment. At the March 2013 spine examination, the examiner found there to be no physical impairment related to the back and neck disabilities and that the Veteran was able to perform sedentary and physical type employment with no limitations. The examiner opined that there were no limitations on physical employment. A March 2013 nerve examination found that the Veteran had persistent lower back pain and left lumbar radiculopathy, and that this might affect to some extent his physical employment status. As discussed above, however, the Veteran does not have lumbar radiculopathy nor is he service-connected for it. The weight of the probative evidence is against the claim. Every medical professional who evaluated the Veteran's has concluded that his service-connected disabilities: PTSD, headaches, back disability and neck disability do not prevent sedentary or physical employment. The March 2013 notation that the Veteran's back pain might affect his employment does not mean that his service-connected disabilities are of sufficient severity to produce unemployability. The disability ratings that he receives are provided in an effort to help offset any employment impairment. The evaluation of whether a TDIU is warranted is limited to the impairment caused by service-connected disabilities alone. The Board cannot consider the impact of non-service connected disabilities. The Veteran has numerous non-service connected disabilities, including but not limited to sleep apnea, left arm weakness and left leg weakness. A vocational assessment was not conducted in this case. However, it is within VA's discretion to determine whether a vocational assessment is required based on the facts of a particular case. Every claim for TDIU does not automatically require a vocational assessment, although the Board is required to at least consider whether a vocational assessment is required and to support its determination that one is not required with an adequate statement of reasons or bases. See Smith v. Shinseki, 647 F.3d 1380, 1386 (Fed. Cir. 2011). Here, the Board obtained the opinions of multiple medical professionals and they provided opinions that the Veteran's service-connected disabilities alone were not of sufficient severity to produce unemployability. These opinions addressed the very matter that a vocational expert would address and a vocational assessment is therefore not considered to be necessary, as it is unclear what benefit a vocational survey would provide given that the Veteran's service-connected disabilities have not been found to produce unemployability. While the Veteran believes that his service-connected disabilities alone are of sufficient severity to produce unemployability, as a lay person, he lacks the medical training and expertise to provide such a complex medical opinion. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, his opinion is insufficient to establish that a TDIU is warranted. Nevertheless, VA endeavored to obtain the opinions of multiple medical professionals, and the ten medical opinions addressing the question of employment and service connected disabilities found that the Veteran was not precluded from substantially gainful employment by his service connected PTSD, headaches, back disability and neck disability alone. The Board acknowledges the fact that the Veteran's service connected disabilities impact his work environment, but this does not mean that they preclude all gainful employment. As such, the preponderance of the evidence is against the claim; and there is no doubt to be resolved. Entitlement to TDIU is therefore denied. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in December 2009 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. With respect to the Dingess requirements, in that same letter, the RO provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the notice requirements with respect to the claims for service connection. With respect to the increased rating claims, it is inherent that the he had actual knowledge of the rating element of the claim. Any questions as to the appropriate effective date to be assigned are moot as the claims have been denied. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained; he did not identify any additional private or VA treatment records pertinent to the appeal. Under Bryant v. Shinseki, the judge who conducts a hearing fulfills two duties to comply with the regulation. They 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. In this case, during the June 2012 Board hearing, the judge identified and fully explained the issue on appeal, and asked questions focused on the elements of service connection needed to substantiate the claims. Furthermore, the VLJ specifically questioned the Veteran regarding outstanding and potentially pertinent records that may have been overlooked, and suggested that such records be obtained. The Veteran was assisted at the hearing by an accredited representative. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) , and that any error in notice provided during the Veteran's hearing constitutes harmless error. Further, the Veteran's Social Security Administration disability determination and the records considered in that determination were obtained in July 2011. In addition, VA examinations were conducted in March 2009, July 2009, three in December 2009, January 2010, two in February 2012, three in March 2013, and April 2013. The examinations were adequate as the examiners reviewed the record, evaluated the Veteran and provided an opinion with supporting rationale as to the cause of his current disabilities or evaluated his current disability level and provided findings to allow for proper application of the rating criteria. Therefore, the available records and medical evidence have been obtained in order to make adequate determinations as to these claims. Significantly, neither the Veteran 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 claims that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. 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). ORDER Service connection for a disability manifested as left side pain due to a lightning strike is denied. Service connection for sleep disorder, to include sleep apnea, claimed as secondary to PTSD, is denied. A rating in excess of 10 percent for chronic lumbosacral strain is denied. A rating in excess of 10 percent for chronic cervical strain is denied. A TDIU is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs