Citation Nr: 1336698 Decision Date: 11/12/13 Archive Date: 11/22/13 DOCKET NO. 07-29 422 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a rating in excess of 10 percent for episodic myotonia with muscle stiffness, right upper extremity, and carpal tunnel syndrome, right wrist (right (minor) upper extremity disability). 2. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran had active service from June 1987 to June 1992 and from May 1993 to September 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In January 2011, the Veteran testified at a video-conference hearing before the undersigned. In June 2007 and again in April 2011, the Board remanded the claim for an increased rating for the right upper extremity disability for additional development. In a June 2008 statement, the Veteran claimed that his service-connected right upper extremity disability greatly interfered with his employment. The Veteran also submitted evidence that his employer granted authorized absence under the Family Medical Leave Act for multiple service-connected disabilities. Therefore, the Board finds that the record raises a claim for a TDIU, so it is included as an issue on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (per curiam) (holding that claims for higher evaluations also include a claim for a total rating based on TDIU when the appellant claims he is unable to work due to a service connected disability). The claim for a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At all times during the pendency of the appeal, the most probative evidence of record shows that the Veteran's right (minor) upper extremity disability is not manifested by adverse symptomatology that equates to at least moderate incomplete paralysis of the median nerve. 2. At all times during the pendency of the appeal, the most probative evidence of record shows that episodic myotonia with muscle stiffness of the right (minor) upper extremity and carpal tunnel syndrome of the right (minor) wrist are manifested by the same adverse symptomatology such that assigning separate ratings would violate the rule against pyramiding. CONCLUSION OF LAW At all times during the pendency of the appeal, the criteria for a rating in excess of 10 percent for the Veteran's right (minor) upper extremity disability and/or separate ratings for episodic myotonia with muscle stiffness of the right upper extremity and carpal tunnel syndrome of the right wrist have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.14, 4.31, 4.124, 4.124a, Diagnostic Code 8515 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 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). Under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See 38 U.S.C. § 5103(a). Initially, the Board notes that there is no issue as to whether the Veteran was provided an appropriate application form or issue as to whether the claimant has veteran status. Next, the Board finds that in letters dated in November 2005, April 2008, June 2008, and May 2011 the RO provided the Veteran with notice that fulfills the provisions of 38 U.S.C.A. § 5103(a) including notice of the laws and regulations governing disability ratings and effective dates as required by the Court in Dingess, supra. Moreover, even though the Veteran was not provided adequate 38 U.S.C.A. § 5103(a) notice prior to the adjudication of the claim in the February 2006 rating decision, the Board finds that providing him with additional notice in the above letters followed by a readjudication of the claim in the March 2012 supplemental statement of the case with an opportunity to respond, "cures" any timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. Furthermore, even if the above letters did not provide adequate 38 U.S.C.A. § 5103(a) notice, the Board finds that this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claim after reading the above letters as well as the rating decision, the statement of the case, the supplemental statements of the case, and the Board remand. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the January 2011 Board hearing, the Veteran was assisted at the hearing by an accredited representative and the representative and the Acting VLJ asked questions to ascertain the current state of the Veteran's disability. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. The Acting VLJ assisted the Veteran in the identification of additional evidence and how submission of that evidence would contribute to the substantiation of his claim. Therefore, the Board finds that, consistent with Bryant, the Acting VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). As to the duty to assist, the Board finds that VA has secured all available and identified pertinent in-service and post-service evidence including the Veteran's service treatment records as well as his post-service records from Tripler Army Hospital and the Lebanon VA Medical Center in substantial compliance with the Board's remand directions. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Veteran was provided VA examinations in October 2004, April 2005, May 2008, March 2011, and May 2011. Moreover, addendums to some of these VA examinations were obtained in October 2004 and January 2005. Furthermore, the Board finds that the examinations and addendums are adequate for rating purposes, and as to the post-remand VA examination substantially complies with the Board's remand directions, because after comprehensive examinations of the claimant as well as after taking a history from the Veteran and/or a review of the record on appeal the examiners provided opinions as to the severity of his disability that allows the Board to rate it under all relevant Diagnostic Codes. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007); Also see Stegall, supra; D'Aries, supra; Dyment, supra. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claim below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in the Virtual VA electronic file system. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims files shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Claim The Veteran asserts that his right upper extremity disability is manifested by adverse symptomatology that equates to the criteria for a higher rating. The Veteran also claims that separate compensable ratings for his episodic myotonia with muscle stiffness of the right upper extremity and carpal tunnel syndrome of the right wrist are warranted. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held that a claimant 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 v. Mansfield, 21 Vet. App. 505 (2007). Separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to 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 evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). The February 2006 rating decision granted a 10 percent rating for episodic myotonia with muscle stiffness, right upper extremity, and carpal tunnel syndrome, right wrist under 38 C.F.R. § 4.124a, Diagnostic Code 8099-8515, effective from September 27, 2004. Because the record shows that the Veteran is left handed, 38 C.F.R. § 4.124a, Diagnostic Code 8515 provides a 10 percent rating for mild incomplete paralysis of the median nerve in the minor upper extremity; a 20 percent rating for moderate incomplete paralysis of the median nerve in the minor upper extremity; a 40 percent rating for severe incomplete paralysis of the median nerve in the minor upper extremity; and a 60 percent rating for complete paralysis of the median nerve in the minor upper extremity. The Board considered whether other Diagnostic Codes, particularly those associated with muscle damage or impairment, are applicable in this case. The Board concludes that the Veteran's neuromuscular disease has been most often evaluated by neurologists and presents symptoms associated with impairment of muscle control by the nervous system and not muscle atrophy or tissue damage. Diagnostic Code 8515 is most applicable because it best contemplates the physiology and functional impairment imposed by the disease. 38 C.F.R. § 4.124a defines the term "incomplete paralysis" as indicating a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.123 provides that neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.124 provides that neuralgia, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). With the above criteria in mind, at the October 2004 VA examination the Veteran complained of a problem with releasing his grip in cold weather and for 20 minutes after vigorous exercise. He also reported having muscle stiffness but not pain at these times. The Veteran also reported that his problems are worse with fatigue, stress, and anxiety. He also reported that it interferes with his job as a correctional officer and trainer because he has trouble releasing his finger from the trigger of his weapon and because it caused him to gain weight because he cannot exercise as much. His history included a 1994 electromyography (EMG) which showed myotonia. However, subsequent EMGs and nerve conduction studies were negative. On examination, cranial nerves II to XII were normal. It was opined that he does not have percussion myatonia. Reflexes were 1+ and equal. His plantar response was flexor and his sensory examination was normal. It was also opined that the Veteran's disability impaired his livelihood because of his inability to let go his firearm trigger and because of his muscle stiffness with exercise. In the January 2005 addendum, it was opined that despite the Veteran's complaints there is no true weakness. The impression was episodic myotonia, stiffness, well muscled without weakness on examination, exacerbated by cold which all pointed to paramyotonia congenital. At the April 2005 VA examination, the Veteran complained of mild numbness on the first two fingers of the right hand as well as weakness in his wrist with prolonged hand/wrist activity. It was also noted that a July 2003 EMG and nerve conduction study showed "mild" right carpal tunnel syndrome and the nerve conduction study conducted as part of this VA examination showed no significant changes since July 2003 with the appellant continuing to have "mild" carpal tunnel syndrome. On examination, there was "very minimal" finger numbness and there was "mild" positive Tinel sign at the wrist. However, there was no muscle atrophy; there was no weakness of abductor or adductor strength; and grip/grasp was within normal limits. The range of motion of the right wrist was also within normal limits. The Veteran provided testimony at a hearing before another VLJ who is no longer employed by the Board. The focus of the hearing was on other service-connected disabilities. However, the Veteran reported that his employer granted leave under the Family Medical Leave Act for multiple disabilities that included left shoulder, lumbar spine, and asthma. He later submitted a related document from his employer that included a service-connected mental health disability currently rated as 50 percent disabling. Thereafter, at the May 2008 VA examination, the Veteran complained of right upper extremity stiffness, cramping, and myotonia as well as fatigue mostly after exercise but without pain or flare-ups. It was also noted that his problems were not seen on examination. Next, it was noted that he was being treated with medication with some success and EMGs in 2006 and 2007 were normal. His neurological examination was unremarkable with cranial nerves II to XII intact and functioning properly. Tinel's and Phalen's examinations were within normal limits. Range of motion of the elbow and wrist were within normal limits without tenderness or change after repetition. Capillary refill was within normal limits. Sensory and vibratory examinations were within normal limits. It was opined that there was no evidence of an active disease of the wrist. Despite the normal examination, the examiner noted that the Veteran's treatment records showed that the working diagnosis from his VA neurologist was channelopathy, stable with medication. In mental health treatment encounters in June 2008 and May 2010, the Veteran reported that he was able to exercise one and one-half hours per day and continued to enjoy camping. In several statements throughout the period of the appeal and in his January 2011 hearing before the undersigned Acting VLJ, the Veteran reported that his myotonia of the right upper extremity caused impairment that was close to causing him to lose his job as a Training Captain at a state correctional institution. His duties included training in firearms, martial arts, and riot control, but he often required assistance from other instructors to avoid the exertion that stimulated his symptoms of muscle immobility. He reported that on occasion he was unable to release his finger from the trigger of his firearm during range training, release his grip on a glass, swim in cold water, or clear snow in cold weather. He reported that he had to warm his automobile before driving in cold weather. At the March 2011 VA spine examination, it was also noted that he had normal 2+ reflexes in his right bicep, triceps, brachioradialis, and finger jerk as well as normal 5/5 motor examination of the right elbow flexion and extension, right wrist flexion and extension, and right finger flexion, abduction, and opposition. Lastly, at the May 2011 VA examination it was reported that the Veteran had difficulty letting go of his hand grip which symptoms were worse when it's cold. He also reported that it continues to cause him problems at work such as when he is teaching martial arts or firing his weapon. Nonetheless, it was noted that the Veteran remains fully employed and has found ways to accommodate his difficulty at work. In this regard, the Veteran has tried a number of medications with only minimal benefit. Repeat CPKs as well as a biopsy were normal but he continues to have elevated triglycerides. Moreover, his neurological examinations have been normal except for some difficulty with apparent blepharospasm which has been granted separate service-connection. On examination, cranial nerves II through XII were normal without ptosis. Deep tendon reflexes were 2+ and equal bilaterally. Plantar responses were flexor. Strength was 5/5 throughout without any obvious myotonia or percussion myotonia. The impression was that the Veteran had a channelopathy in the family of disease of paramyotonia so that his disorder is characterized by muscle stiffness in the cold with stress and with repeated use. VA treatment records periodically document the Veteran's complaints and treatment for right upper extremity stiffness in cold weather being treated with medication. Moreover, on one occasion in February 2003 they note that the Veteran's deep tendon reflexes were "perhaps slightly diminished" and in other treatment records they note "mild" reflex depression (see, for example, VA treatment records dated in March 2006, January 2007, and August 2007). However, nothing in these records contradicts the above VA examiners opinions as to the severity of his adverse neurological symptomatology. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). The Veteran is competent to report his observed symptoms and functional impairment. The Board concludes that his reports of right upper extremity impairment under extreme weather conditions and after exertion are generally credible as they have been accepted by clinicians even though objective medical testing and examination do not entirely support the degree of severity described by the Veteran. The Board acknowledges that the Veteran was never examined in an extreme cold, hot, or post-exercise situation. However, the Board accepts the Veteran's reports that these situations caused cramping and immobility of muscles of the right upper extremity. Nevertheless, the Board places somewhat less probative weight on the impact of the impairment on his occupation and daily activities. The Veteran reported that he is able to avoid circumstances such as working or swimming in cold environments, warming his vehicle before driving, and exercising under controlled conditions. Although he reported the imminent loss of his job as an instructor, he continues to work in this position. His exercise of Family Medical Leave Act benefits is only in small part related to the dysfunction of the right upper extremity. In summary, the record shows that the Veteran's adverse symptomatology is limited to his subjective complaints of problem with releasing his grip and muscle stiffness as well as objective evidence of "very minimal" finger numbness and "mild" positive Tinel sign at the wrist at one VA examination in 2008, "perhaps slightly diminished" deep tendon reflexes in one treatment record, and "mild" reflex depression in other treatment records. Otherwise the Veteran's VA neurological examinations are uniformly normal with no adverse symptomatology such as muscle atrophy or weakness. Moreover, July 2003 and April 2005 EMG and/or nerve conduction studies characterized the severity of the Veteran's carpal tunnel syndrome as "mild" and this medical opinion is not contradicted by any other medical evidence of record. See Colvin, supra. Therefore, while the term "moderate" incomplete paralysis of the median nerve is not defined by regulation, the Board finds that it must mean more than the minimum adverse symptomatology manifested by this Veteran which symptomatology has uniformly been characterized as "mild." Accordingly, the Board finds that the claim for an increased rating for the right upper extremity disability under Diagnostic Code 8515 is denied. 38 C.F.R. § 4.124a. The Board finds that this is true at all times during the pendency of the appeal because the severity of the Veteran's adverse symptomatology has been substantially the same during this time. See Hart, supra. As to the Veteran's claim that he is entitled to separate compensable ratings for his episodic myotonia with muscle stiffness of the right upper extremity and carpal tunnel syndrome of the right wrist, the Board notes that both disabilities are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8515 because they are both disabilities of the median nerve affecting function of the lower arm and hand. Therefore, the Board finds that the claim for separate compensable ratings must be denied at all time during the pendency of the appeal because it would violate the rule against pyramiding by paying the Veteran twice for the same adverse symptomatology. See 38 C.F.R. § 4.14. See Hart, supra. Based on the Veteran's and his representative's claims that the appellant's right upper extremity disability is worse than rated, the Board will consider the application of 38 C.F.R. § 3.321(b)(1) (2013). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found 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 veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the right upper extremity disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's condition with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Moreover, higher ratings are available for a more severe level of impairment or partial paralysis. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." Specifically, there simply is no objective evidence that his right upper extremity disability, acting alone, has resulted in frequent periods of hospitalization or in marked interference with employment. See Bagwell v. Brown, 9 Vet. App. 337 (1996). In this regard, while the Veteran provided voluminous employment records documenting his claims that he lost significant time from work, none of these records identify his right upper extremity disability as the sole reason for all of his lost time. In this regard, February 2010 VA treatment records noted that the Veteran was getting help from VA to obtain medical leave from work and, while these records noted both his right upper extremity disability and his psychiatric disorders, they also noted that the claimant was seeking the time off mainly because of his psychiatric disorders. Moreover, while most of the VA examiners reported that his disability caused him problems at work, none of them reported that it significantly interfered with work. In fact, at the May 2011 VA examination it was noted that the Veteran was fully employed and has found ways to accommodate his difficulty at work. Therefore, the Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that this service-connected disability causes impairment with employment over and above that which is contemplated in the assigned schedular ratings. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. In reaching the above conclusions, the Board has not overlooked the various lay statements found in the record. In this regard, the Veteran is credible to report on what he sees and feels and others are credible to report on what they can see. See Davidson, supra. However, the Board finds more probative the medical opinions as to the severity of his disability provided by the experts at the Veteran's VA examinations than these lay assertions. See Black v. Brown, 10 Vet. App. 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators. . ."). The Board has also considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim, the Board finds that this doctrine is not for application. 38 U.S.C.A. § 5107(b); see also, e.g., Gilbert. ORDER A rating in excess of 10 percent for the Veteran's right (minor) upper extremity disability and separate ratings for episodic myotonia with muscle stiffness of the right upper extremity and carpal tunnel syndrome of the right wrist is denied at all times during the pendency of the appeal. REMAND As explained above, the record raises a claim for a TDIU. See Rice, supra. However, the Board finds that the TDIU issue is not as yet fully developed for appellate review. Specifically, the Board notes that the Veteran has not been provided with notice of the laws and regulations governing a TDIU in a statement of the case or supplemental statement of the case or an adequate examination to obtain an opinion as to whether his service connected disabilities prevent him from working. See 38 U.S.C.A. §§ 5103(a), 5103A(b) (West 2002); 38 C.F.R. § 19.31 (2013); McLendon v. Nicholson, 20 Vet. App. 79, 84-86 (2006). Therefore, the Board finds that a remand for such development is required. The Veteran reported that he receives ongoing treatment from the Lebanon VA Medical Center. However, his post-March 2012 treatment records are not found in the claims file. Therefore, the Board finds that while the appeal is in remand status these treatment records should be obtained and associated with the claims file. See 38 U.S.C.A. § 5103A(b) (West 2002); Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that VA adjudicators are deemed to have constructive notice of VA treatment records). Accordingly, this issue is REMANDED to the RO/AMC for the following actions: 1. Associate with the claims file, physically or electronically, all of the Veteran's post-March 2012 treatment records from the Lebanon VA Medical Center. All actions to obtain the requested records should be documented fully in the claims file. 2. Provide the Veteran with notice of the laws and regulations governing a TDIU in accordance with 38 U.S.C.A. § 5103A (West 2002). 3. After undertaking the above development to the extent possible, provide the Veteran with an appropriate TDIU VA examination, to be conducted, if possible, by a vocational rehabilitation specialist. The claims file should be made available to the examiner and all appropriate tests should be performed. The examiner must opine as to whether, without regard to the Veteran's age or the impact of any nonservice-connected disabilities, it is at least as likely as not that his service-connected disabilities, alone or in the aggregate, render him unable to secure or follow any substantially gainful occupation. In offering this impression, the examiner must acknowledge and take into account this Veteran's education, training, and work history. All finding and conclusions should be set forth in a legible report, accompanied by a rationale. 4. After undertaking any other needed development, adjudicate the claim for a TDIU. If the benefit sought on appeal is not granted in full, the Veteran should be provided a supplemental statement of the case (SSOC) that includes notice of all relevant the laws and regulations governing a TDIU as well as citation to all evidence received since the issuance of the March 2012 supplemental statement of the case. A reasonable period of time should be allowed for response before the appeal is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J.W. FRANCIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs