Citation Nr: 1335963 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 09-13 720 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 10 percent for lumbar spine strain, effective April 2, 2009. 3. Entitlement to a rating in excess of 20 percent for lumbar spine strain, effective July 18, 2011. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from October 1982 to February 1992. This case was previously before the Board of Veterans' Appeals (Board) in June 2011 and October 2012. Each time, it was remanded for further development. In June 2011, the Board noted that the Veteran had been afforded a VA examination in October 2009. The examiner diagnosed the Veteran with a lumbar back strain, concluding that the lumbar spine muscle strain is less likely than not related to service. However, the examiner also noted that the examination and x-rays demonstrated dextroscoliosis, indicating that this condition was not related to the Veteran's service because the "predisposition" for this condition preceded his service. The examiner concluded that there was no indication that activities in service would have aggravated this condition. The Board found the October examination inadequate for rating purposes. The Board noted that report of the Veteran's September 1982 induction physical examination had not contained any complaints, treatment, or diagnosis of a back condition. As such, the Board concluded that the record raised questions as to whether the Veteran's low back had been in sound physical condition at the time he entered service. In June 2011, the Board reported that in September 2009, the RO had made a formal finding of unavailability of Milwaukee VA outpatient treatment records pertaining to the lumbar and thoracic spine condition(s) for the period of January 1, 1997 through December 31, 2003. The Board noted that the Veteran has not been sent notice of that finding. Regarding the issue of entitlement to a disability evaluation in excess of 50 percent for service-connected PTSD, the Board found that additional evidence had been added to the claims folder subsequent to the issuance of a statement of the case (SOC) in February 2009 but that the RO has not had a chance to review that evidence. In light of the foregoing, the Board directed the RO to perform the following actions: 1. Obtain clinical records of the Veteran's VA treatment since January 2009. 2. Inform the Veteran via letter of the September 2009 formal finding of unavailability of the Milwaukee VA outpatient treatment records pertaining to the lumbar and thoracic spine condition (s) for the period of January 1, 1997 through December 31, 2003. 3. Schedule the Veteran for orthopedic examination to identify all thoracolumbar spine disorders present and their likely etiology. In October 2012, the Board determined that the Veteran had submitted new and material evidence to reopen his previously denied claim for service connection for a disorder of the thoracolumbar spine. Therefore, the Board noted that a de novo review of the evidence was warranted. The Board also noted that the Veteran last underwent a VA psychiatric examination in January 2012 for the purpose of determining the severity of his PTSD but that more recent VA outpatient treatment records showed him feeling "more depressed." As such, the Board directed the RO to obtain any pertinent VA or other inpatient or outpatient treatment records, subsequent to June 2012 and to schedule the Veteran for additional VA orthopedic and psychiatric examinations in order to more accurately determine the exact nature and etiology of his current low back disability and the severity of his service-connected PTSD. Following the requested development, the RO granted the Veteran's claim of entitlement to service connection for lumbar spine strain and assigned an initial rating of 10 percent for the period from April 2, 2009 through July 18, 2011 and a 20 percent rating effective July 19, 2011. The RO confirmed and continued the initial 50 disability rating for his service-connected PTSD. Thereafter, the case was returned to the Board for further appellate action. FINDINGS OF FACT 1. Since service connection became effective May 2, 2002, the Veteran's PTSD has been productive of no more than occupational and social impairment with reduced reliability and productivity. 2. For the period, effective April 2, 2009 through July 17, 2011, the Veteran's lumbar spine strain was manifested primarily by tenderness to palpation and limitation of motion with flexion to 85 degrees; extension to 5 degrees; lateral flexion to 15 degrees, bilaterally; and rotation to 5 degrees, bilaterally. 3. Since July 18, 2011, the Veteran's lumbar spine strain has been manifested primarily by tenderness to palpation and limitation of motion with flexion to as little as 45 degrees; extension to as little as 10 degrees; right lateral flexion to as little as 20 degrees; left lateral flexion to as little as 30 degrees; and rotation to as little as 30 degrees, bilaterally. CONCLUSIONS OF LAW 1. Since service connection became effective May 2, 2002, the Veteran's PTSD has not met the criteria for a rating in excess of 50 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130, Diagnostic Code 9411 (2013.) 2. For the period, effective April 2, 2009 through July 18, 2011, the Veteran's lumbar spine strain has not met the criteria for a rating in excess of 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71A, Diagnostic Code 5237 (2013.) 3. Since July 19, 2011, the Veteran's lumbar spine strain has not met the criteria for a rating in excess of 20 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71A, Diagnostic Code 5237 (2013.) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Prior to consideration of the merits of the Veteran's appeal, the Board must determine whether VA has met its statutory duty to assist him in the development of his claims of entitlement to a increased ratings for PTSD and lumbar spine strain. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. In May 2002 and in July 2005, respectively, the RO received the Veteran's substantially complete applications to reopen his previously denied claims of entitlement to service connection for PTSD and for a low back disorder. Following the receipt of those applications, the RO notified the Veteran of the information and evidence necessary to substantiate his claims, including the evidence to be provided by him and notice of the evidence VA would attempt to obtain. VA informed him of the criteria for service connection, as well as the deficits in the evidence in his prior denials. VA also informed him of the criteria for rating service-connected disabilities and for assigning effective dates, should service connection be granted. Following the notices to the Veteran, VA fulfilled its duty to assist him in obtaining the identified and available evidence necessary to substantiate his claims. VA obtained or ensured the presence of records and reports reflecting his VA treatment from September 2003 through January 2012, an August 2004 statement from the Veteran's wife; numerous articles from the internet and other publications; and a March 2012 statement from the Social Security Administration stating that it did not have any medical evidence on file concerning the Veteran. In September 2003, December 2004, September 2005, August 2008, January and October 2009, August 2010, July 2011, and January and December 2012, VA examined the Veteran to determine the nature and extent of impairment attributable to his PTSD and his low back disorder. The VA examination reports show that the examiners reviewed the Veteran's medical history, interviewed and examined the Veteran, documented his medical conditions, and rendered diagnoses and opinions consistent with the remainder of the evidence of record. Therefore, the Board concludes that the VA examinations are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2013); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Finally, VA offered the Veteran an opportunity to present additional evidence and argument at a hearing on appeal. However, to date, he has declined to accept that offer. In May 2007, the RO granted the Veteran's claim of entitlement to service connection for PTSD. Ultimately, the RO assigned a 50 percent schedular rating for that disorder, effective May 2, 2002. In January 2013, the RO granted the Veteran's claim of entitlement to service connection for lumbar spine strain, for which it assigned a 10 percent rating, effective April 2, 2009 and a 20 percent rating, effective July 18, 2011. The Veteran disagreed with the foregoing rating percentages, and this appeal ensued. Inasmuch as it is derived from the initial service connection claim, the issue of entitlement to an increase rating is considered a "downstream" issue. Grantham v. Brown, 114 F.3d 1156 (1997). Although VA has not specifically notified the Veteran of the information and evidence necessary to substantiate the increased rating claim, such notice is not required in this case. In December 2003, the VA General Counsel issued a precedential opinion stating that, if VA received a notice of disagreement (NOD) in response to a decision on a claim for which VA had already sent the Veteran a duty to assist letter, and the NOD raised a new issue, the duty to assist the Veteran did not require VA to provide notice of the information and evidence necessary to substantiate the newly raised "downstream" issue. See VAOGCPREC 8-03. The Board is bound by that opinion. 38 U.S.C.A. § 7104(c) (West 2002); 38 C.F.R. § 19.6 (2013). Hence, VA has essentially complied with its duty to assist the Veteran in the development of his claims of entitlement to increased ratings for PTSD and for lumbar spine strain. In sum, the Veteran has been afforded a meaningful opportunity to participate in the development of his appeal. He has not identified any outstanding evidence which could support any of his claims; and there is no evidence of any VA error in notifying or assisting the Veteran that could result in prejudice to him or that could otherwise affect the essential fairness of the adjudication. Accordingly, the Board will proceed to the merits of the appeal. The Merits of the Appeal Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of VA's Schedule For Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. Generally, the relevant temporal focus for adjudicating the level of disability of an increased rating claim is from the time period one year before the claim was filed until VA makes a final decision on the claim. 38 U.S.C.A. § 5110(b)(2) (West 2002); 38 C.F.R. § 3.400(o)(2) (2012). Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, a veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (When service connection is granted and an initial rating award is at issue (as in this case with respect to radiculopathy of the left lower extremity) separate ratings can be assigned for separate periods from the time service connection became effective.). Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. PTSD PTSD is rated in accordance with the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for PTSD, when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. Relevant to an evaluation of the level of impairment caused by PTSD is the score on the Veteran's Global Assessment of Functioning (GAF) Scale. That scale is found in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994) (DSM-IV) and reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996). The nomenclature in DSM IV has been specifically adopted by VA in the evaluation of mental disorders. 38 C.F.R. § 4.125, 4.130 (2013). A GAF of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. DSM IV at 32; see Carpenter v. Brown, 240, 242 (1995). A GAF score of 41 to 50 signifies serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). DSM IV at 32; see Richard v. Brown, 9 Vet. App. 266, 267 (1996)). While important in assessing the level of impairment caused by psychiatric illness, the GAF score is not dispositive of the level of impairment cause by such illness. Rather, it is considered in light of all of the evidence of record. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003); Bowling v. Principi, 15 Vet. App. 1, 14 (2001). The Veteran contends that the initial 50 percent rating for his service-connected PTSD does not adequately reflect the level of impairment caused by that disorder. Therefore, he maintains that an increased rating is warranted. However, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against that claim. Accordingly, the appeal will be denied. In August 2004, the Veteran's wife reported that he frequently complained of fatigue and difficulty with his memory. She also reported that he had no patience and was easily angered. A review of the evidence discloses that VA has followed the for PTSD since approximately February 2004. Those records show that since service connection became effective May 2, 2002, the primary manifestations have been disturbed sleep, nightmares, depressed and anxious moods, irritability, anger, a restricted affect and dysphoric mood, attention deficits, and panic attacks less than once a week. Such manifestations were essentially the same as those found during VA psychiatric examinations in September 2003, January 2009, August 2010, and January and December 2012. Generally, the VA health care providers and examiners found the Veteran's PTSD symptoms compatible with a GAF of 48 to 50, a GAF indicative of serious impairment. However, the Veteran remained alert and well-oriented without suicidal ideation; obsessional rituals which interfered with his routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting his ability to function independently, appropriately and effectively; periods of violence; spatial disorientation; the neglect of his personal appearance and hygiene; impaired thought processes; or delusions or hallucinations. The Veteran remained able to independently perform the activities of daily living, such as preparing meals, dressing himself, and toileting. Moreover, the evidence such as the report of his January 2009 VA examination shows that he was able to go places beyond walking distance and to perform various chores, such as , yard work, snow shoveling, and grocery shopping, as well as do laundry and other housework. In addition it was noted that he had worked for the Post Office for many years and that his PTSD was productive of no more than occupational and social impairment with an occasional decrease in work deficiency. In July 2012, the Veteran's representative noted that the February 1, 2012, VA neurologic examination found that the Veteran had a tremor, dizziness, balance problems, and headaches, due to anxiety. He further noted that the VA psychiatric examination reports did not include those symptoms when assessing the Veteran's overall impairment due to his service-connected PTSD. Indeed, none of the multiple VA psychiatric examiners who reviewed the claims file in January 2009, August 2010, January 2012, and December 2012, confirmed those findings as manifestations of his PTSD. As specialists in the fields of psychiatry and psychology, the Board places greater weight on their ability to identify the symptoms of PTSD than that of a specialist in neurology. Moreover, the VA examiners did not find that the Veteran's PTSD symptoms were productive of any more than occupational and social impairment with reduced reliability and productivity. On balance the foregoing manifestations of the Veteran's PTSD and the resulting impact on his ordinary activities reflect no more than the criteria for a 50 percent schedular rating. Accordingly, that rating is confirmed and continued, and the appeal is denied. The Lumbar Spine The Veteran also seeks entitlement to increased ratings for his service-connected lumbar spine strain. As above, he contends that the initial 10 percent rating effective April 2, 2009 and the 20 percent rating, effective July 18, 2011, do not adequately reflect the levels of impairment caused by that disorder. Therefore, he maintains that increased ratings are warranted. Again, however, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against that claim. Accordingly, the appeal will be denied. The Veteran's lumbar spine strain is rated on the basis of the following general rating formula: General Rating Formula for Diseases and Injuries of the Spine The noted ratings may be assigned 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. A 10 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, when the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, when muscle spasm, guarding, or localized tenderness does not result in an abnormal gait or abnormal spinal contour; or, when there is a vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, when 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 40 percent rating is warranted when forward flexion of the thoracolumbar spine is accomplished to 30 degrees or less or when there is favorable ankylosis of the entire thoracolumbar spine. 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. General Rating Formula for Diseases and Injuries of the Spine, 38 C.F.R. § 4.71A, Diagnostic Code 5237, Note (5). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40 ; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In August 2004, the Veteran's wife reported that the Veteran complained that his back hurt all the time and that work was getting too hard with his joints and muscles hurting. For the period from April 2, 2009 through July 18, 2011, the VA treatment records and the report of the October 2009 VA examination, show that the Veteran's lumbar spine strain was manifested primarily by tenderness to palpation and limitation of motion. The VA examination report shows that his combined range of 130 degrees of lumbar spine motion consisted of flexion to 85 degrees; extension to 5 degrees; rotation to 5 degrees, bilaterally; and lateral flexion to 15 degrees, bilaterally. Repetitive testing did not result in painful flare-ups, weakness, lack of incoordination, or instability. Although the Veteran walked with a mildly antalgic gait and X-rays revealed mild dextroscoliosis, there was no evidence of associated muscle spasm or guarding, nor was there any effusion, edema, or erythema. Except for a patchy area around his heel, his sensation was within normal limits. His deep tendon reflexes were also normal, as was his strength without evidence of atrophy or impaired tone. As noted above, the Veteran continued to perform his ordinary activities. He had reportedly worked for the Post Office for many years in a manual labor job, and he was able to perform the activities of daily living. His back disorder did not prevent him from going places beyond walking distance, and he performed many household chores, including the laundry, shopping, and yard work. In light of the manifestations and the resulting impact on his ordinary activities, the Board finds that for the period from April 2, 2009 through July 18, 2011, the Veteran's back disorder met or more nearly reflected the schedular criteria for no more than a 10 percent rating. Accordingly, an increased rating is not warranted, and the appeal is denied. Since July 19, 2011, the Veteran's treatment records and July 2011 and December 2012 VA examinations show that his service-connected lumbar spine strain has continued to be manifested primarily by tenderness to palpation and limitation of motion. There is no evidence of ankylosis as he demonstrates flexion to 45 degrees; extension to 10 degrees; right lateral bending to 20 degrees on the right and 30 degrees on the left; and rotation to 45 degrees, bilaterally. The limitation of flexion is compatible with the criteria for a 20 percent rating, and there is no change in motion with repetitive testing. The Veteran's muscle function remains full without atrophy, and his reflexes and sensation are normal. Although lifting at work causes short flare-ups, the most recent examiner found that the Veteran's low back disorder did not limit his walking or daily activities, nor did it otherwise impact his ability to handle mail and parcels and to drive a fork lift. For these reasons, the Board finds that since July 19, 2011the Veteran's low back disorder has met or more nearly approximated the criteria for the 20 percent rating currently in effect. Accordingly, an increased rating is not warranted, and that portion of the appeal is also denied. Additional Considerations In arriving at the foregoing decisions, the Board has considered the numerous articles submitted in support of his claims. However, with the exception of an article on the first fight in the 1991 Iraq War, they do not identify the Veteran, specifically, or the manifestations or effect of his service-connected PTSD or lumbar spine disorder. As such, they are not probative of his claims for increased ratings. The Board has also considered the possibility of referring this case to the Director of the VA Compensation and Pension Service for the potential approval of an extraschedular rating for the Veteran's service-connected PTSD and lumbar spine strain. 38 C.F.R. § 3.321(b)(1) (2013). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111, 114 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun, 22 Vet. App. at 115. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare 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. Id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular evaluation is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors, such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. In this case, neither the Veteran nor his representative have expressly raised the matter of entitlement to an extraschedular rating. The Veteran's contentions have been limited to those discussed above, i.e., that his disability is more severe than is reflected by the currently assigned schedular rating. See Brannon v. West, 12 Vet. App. 32 (1998) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). The criteria for rating psychiatric disorders specifically contemplate the primary symptoms of the Veteran's service-connected PTSD, disturbed sleep, nightmares, depressed and anxious moods, irritability, anger, a restricted affect and dysphoric mood, attention deficits, and panic attacks less than once a week. 38 C.F.R. § 4.130, Diagnostic Code 9411. Likewise, the criteria for rating back disorders specifically contemplate the primary symptoms of the Veteran's service-connected lumbar spine strain, tenderness to palpation and limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5237. In short, the Veteran does not have symptoms associated with his PTSD or lumbar spine strain that have been left uncompensated or unaccounted for by the assignment of a schedular rating. Thun, 22 Vet. App. at 115. Therefore, the preponderance of the evidence is therefore against a finding that either of those disorders presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Accordingly, further action is not warranted under 38 C.F.R. § 3.321 (b)(1) . ORDER Entitlement to an initial rating in excess of 50 percent for PTSD is denied. Entitlement to an initial rating in excess of 10 percent for lumbar spine strain, effective April 2, 2009, is denied. Entitlement to a rating in excess of 20 percent for lumbar spine strain, effective July 18, 2011, is denied. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs