Citation Nr: 1338501 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 07-28 076A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to a rating in excess of 20 percent for degenerative arthritis of the lumbar spine. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from January 1962 to January 1965 and from April 1984 to September 2002. This matter comes before the Board of Veterans' Appeals (Board) from a December 2005 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Montgomery, Alabama. In June 2011, the Veteran testified during a Board hearing before the undersigned Acting Veterans Law Judge (VLJ) at the RO; a transcript of that hearing is of record. During the hearing, the Veteran requested, and was granted, a 30-day abeyance to submit additional evidence. In June 2011, the Veteran submitted additional evidence accompanied by a waiver of initial RO consideration of the evidence. This evidence has been accepted for inclusion in the record on appeal and considered as appropriate. See 38 C.F.R. §§ 20.800, 20.1304 (2013). In Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ or Acting VLJ who chairs 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. At the hearing, the undersigned AVLJ clarified the issues in appellate status, elicited relevant testimony, and verified the Veteran's treatment sources. The AVLJ also suggested that it might be helpful to obtain a medical examination and/or opinion in the case. As such, the Board finds that it has fully complied with the Bryant requirements. To the extent there were any deficiencies in the conduct of the hearing, they were cured with Board development of the case. This case was previously before the Board in January 2012, at which time 3 claims were in appellate status and 1 was in quasi-appellate status. The Board denied a service connection claim for prostate cancer, and granted a claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), fully resolving those 2 claims. The remaining claims of entitlement to a rating in excess of 20 percent for degenerative arthritis of the lumbar spine and entitlement to a rating in excess of 40 percent for chronic prostatitis were remanded. Subsequently, the Veteran perfected an appeal for the claim involving chronic prostatitis, giving it appellate status. While pending consideration by the Board, the benefit sought was granted in full, resolving the claim. In this regard, in a rating action issued in April 2012, a 60 percent evaluation (the maximum provided under the applicable rating criteria of 38 C.F.R. § 4.115a, diagnostic code 7527) was granted effective from April 13, 2009, the date the Veteran filed an increased rating claim for this disability. The Veteran did not raise the issue of entitlement to extraschedular consideration under 38 C.F.R. § 3.321(b), and a TDIU rating is in effect. Accordingly, that claim is not in appellate status before the Board. With respect to the only matter in appellate status at this point, the claim of entitlement to a rating in excess of 20 percent for degenerative arthritis of the lumbar spine, there has been substantial compliance with the actions and directives requested in the January 2012 Board Remand, and the case has returned to the Board for appellate consideration. See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). A November 2013 review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDING OF FACT At no time during the appeal period extending from July 14, 2005 (when the increased rating claim was filed), has the Veteran's service-connected low back disability been manifested by forward flexion of the lumbar spine limited to 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; or incapacitating episodes of intervertebral disc syndrome (IVDS) having a total duration of at least 6 weeks during any 12-month period. CONCLUSION OF LAW For the appeal extending from July 14, 2005, the criteria for an evaluation in excess of 20 percent for a disability of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.25, 4.26, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5242, 5243 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify & to Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements) With respect to the increased rating claim for a low back disorder, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). The file contains duty to assist letters issued in July 2005, and January and March 2006, relating to the Veteran's increased rating claim for a low back disorder. Those letters addressed the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, and provided notice regarding how disability ratings and effective dates are assigned. Thus it is clear the Veteran had actual knowledge of, and has acted on, the information and evidence necessary to substantiate the pending claim. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (Court was convinced that appellant and representative had demonstrated actual knowledge of the information and evidence necessary to establish the claim). Accordingly, the Board concludes that during the administrative appeal process, the Veteran was provided the information necessary such that the purposes of the notification have been met. Under the VCAA, VA also has a duty to assist the Veteran in the development of a claim. This includes assisting the Veteran in procuring service treatment records (STRs) and other relevant treatment records and providing a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, VA obtained the Veteran's STRs, as well as VA and private treatment records. Records and a decision from the Social Security Administration (SSA) were also obtained and associated with the file. The Veteran presented testimony at a travel Board hearing held in June 2011. VA's duty to assist includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). During the appeal period, numerous VA examinations were conducted between 2005 and 2012 and there have been no assertions made that any one of these was inadequate in any way. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). Moreover, the Board finds that such examinations are adequate in order to evaluate the Veteran's low back disability as they include an interview with the Veteran and recordation of his lay reports of symptomatology, a review of the record, and a full clinical evaluation, addressing the relevant rating criteria. The Board finds no credible lay or medical evidence of an increased severity of disability since this examination. Thus, further examination is not warranted. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. Factual Background Service connection was established for chronic low back pain in an October 2002 rating action, for which an initial 10 percent evaluation was assigned effective from October 1, 2002, the first day following the Veteran's discharge from service. On July 14, 2005, the Veteran filed an increased rating claim for his low back disability. Private medical records dated in 2005 reflect that the Veteran was seen in February for complaints of aching pain. Examination revealed normal range of motion and strength and general osteoarthrosis was diagnosed. When seen again in June 2005 for complaints of pain, the Veteran reported that the intensity was mild and it was noted that symptoms appeared to be improving. Examination revealed normal range of motion and strength and low back pain was diagnosed. A VA examination of the spine was conducted in August 2005. The Veteran reported that post-service, he elected to retire due to valvular heart disease and low back pain. It was noted that he had not experienced any periods of incapacitation within the past year. On physical examination, gait was slow, but normal. Moderate loss of normal lumbar lordosis was reported. Range of motion testing of the lumbar spine revealed: flexion to 45 degrees with pain during the latter 15 to 20 degrees; extension to 0 degrees; and lateral bending of 20 degrees bilaterally, with pain. Motor and sensory functions to light touch were entirely normal in the lower extremities. There was no increased limitation of motion due to weakness, fatigability, or incoordination, following repetitive use. X-ray films revealed early lower lumbar spine facet arthopathy. Degenerative disease of the lumbar spine was diagnosed. In a December 2005 rating action, an increased evaluation of 20 percent was granted, effective from July 14, 2005. Private medical records of 2006 and 2007 reflect that the Veteran was having low back pain. Treatment during that time included a short course of steroids, pain medication, and a back brace. A VA examination of the spine was conducted in May 2007. The Veteran reported that he had periods of back pain which put him in bed for up to 4 days at a time, at least once a month. Symptoms of urinary frequency and urgency were described by the examiner as unrelated to the back disability. The Veteran acknowledged having symptoms of decreased motion, pain and stiffness, but not fatigue, weakness or spasms, or radiating pain. The report indicated that the Veteran used a cane and was unable to walk more than a few yards. Objective symptoms included spasms, guarding, pain on motion, and tenderness, without evidence of atrophy or weakness. None of the reported symptoms were found to be severe enough to be responsible for abnormal gait or spinal contour. There was no evidence of ankylosis, kyphosis, listing, scoliosis or lordosis, but lumbar flattening was shown. Range of motion testing of the lumbar spine revealed: flexion to 50 degrees with limitation of motion on repetitive use of 20 to 50 degrees; extension from 0 to 10 degrees with no limitation of motion on repetitive use; left lateral flexion was to 14 degrees right lateral flexion was to 20 degrees, with no limitation of motion on repetitive use; rotation was to 22 degrees on the left side and 12 degrees on the right side, with no limitation of motion on repetitive use. X-ray films revealed mild degenerative joint disease (DJD) of the lumbar spine. Mild degenerative arthrosis of the lumbar spine was diagnosed. In March 2009 a private MRI study of the lumbar spine was undertaken in conjunction with the Veteran's reports of a 15 year history of low back pain, worsening over the past 3 months with radiation into both hips and legs. Impressions of early degenerative disc disease at L4-5 and L5-S1 and moderate degenerative canal stenosis at L3-4 were made. A VA examination of the spine was conducted in April 2010. The Veteran reported having back pain estimated as 3/10 in severity increasing to 7-8/10 by the end of a day. He stated that he experienced severe episodes every 4 to 6 weeks, lasting up to 10 days and requiring bed rest for 7 days, during which times he took Advil. Symptoms of urinary frequency and urgency were described by the examiner as unrelated to the back disability. The Veteran acknowledged having symptoms of decreased motion, pain and stiffness, but not fatigue, weakness, spasms. The report indicated that the Veteran reported having incapacitating episodes of spinal disease, occurring 6 times over the past year, although the Veteran could not provide any dates. He stated that each episode lasted 7 to 10 days. The report indicated that the Veteran used a brace and was unable to walk more than a few yards. Objective symptoms included pain on motion, and tenderness, without evidence of atrophy, weakness, spasms, or guarding. None of the reported symptoms were found to be severe enough to be responsible for abnormal gait or spinal contour. There was no evidence of ankylosis, kyphosis, listing, scoliosis or lordosis, or lumbar flattening. Range of motion testing of the lumbar spine revealed: flexion to 51 degrees; extension from 0 to 2 degrees; right and left lateral flexion to 17 degrees; left lateral rotation to 16 degrees; and right lateral rotation to 19 degrees, with objective pain on motion testing. Additional limitation due to pain on repetitive testing revealed further findings of : flexion to 42 degrees; extension from 0 to 2 degrees; right lateral flexion to 17 degrees; left lateral flexion to 16 degrees; left lateral rotation to 14 degrees; and right lateral rotation to 18 degrees. X-ray films revealed mild DJD of the lumbar spine, described as unchanged from the prior study. Mild degenerative arthrosis of the lumbar spine was diagnosed. On general medical examination of November 2010, essentially the same clinical findings as detailed above were made, but a diagnosis of degenerative disc disease of the lumbar spine with radiculopathy was made. SSA records reveal that disability benefits were approved effective from May 2003 for a primary diagnosis of status post aortic valve replacement, with a secondary diagnosis of spinal stenosis. The Veteran presented at testimony at a travel Board hearing held in June 2011. He stated that he had experienced incapacitating episodes for 8 to 10 weeks a year (p. 6). He complained of right leg pain and left leg instability, pain, weakness, tingling, and numbness, which he attributed to the back disability (p. 11). Another VA examination of the spine was conducted in January 2012. The Veteran reported having back pain estimated as 3/10 in severity increasing to 7-8/10 by the end of a day. He stated that he experienced severe episodes every 4 to 6 weeks, lasting up to 10 days and requiring bed rest for 7 days, during which times he took Advil. Range of motion testing of the lumbar spine revealed: flexion to 45 degrees; extension to 15 degrees; right and left lateral flexion to 15 degrees; and right and left lateral rotation to 15 degrees; with pain on testing. There was no additional limitation of motion on repetitive testing. The Veteran acknowledged having symptoms of less movement that normal, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing, and/or weight bearing. There was no indication of guarding or muscle spasms. The examiner specifically found that the Veteran did not have intervertebral disc syndrome (IVDS) and according had no incapacitating episodes during the past 12 months due to IVDS. The examiner also found that the Veteran did not have neurological symptomatology such as bowel or bladder problems related to the back disability. Occasional use a cane for mobility was reported. Degenerative disc disease (DDD) of the lumbar spine was diagnosed. Pursuant to a January 2012 Board Remand, VA examinations of the spine and peripheral nerves were conducted in March 2012. On VA examination of the spine, the Veteran complained of daily moderate low back pain, as well as severe pain occurring once a month and lasting a week. Pain going down the legs was also recorded. Range of motion testing of the lumbar spine revealed: flexion to 55 degrees; extension to 5 degrees; right and left lateral flexion to 10 degrees; and right and left lateral rotation to 10 degrees; with pain on testing. There was no additional limitation of motion on repetitive testing. The Veteran acknowledged having symptoms of less movement that normal, pain on movement, and interference with sitting, standing, and/or weight bearing. There was no indication of guarding or muscle spasms. Physical examination revealed a positive straight leg raising test on both the left and right side. The examination report indicated that a positive test suggests radiculopathy, often due to disc herniation. The Veteran complained of pain and weakness in the legs, left greater than the right. Severe intermittent radicular pain in both the left and right lower extremity with constant moderate pain in both legs was also noted. There was evidence of mild paresthesias and/or dyesthesias in the right lower extremity, and moderate paresthesias and/or dyesthesias in the left lower extremity. Mild numbness in the right lower extremity and moderate numbness in the left lower extremity was also shown. The nerve roots involved were identified as L4, L5, S1, S2, and S3 (sciatic nerve) in both lower extremities. The examiner specifically found that the Veteran did not have IVDS and according had no incapacitating episodes during the past 12 months due to IVDS. The examiner also found that the Veteran did not have neurological symptomatology such as bowel or bladder problems related to the back disability. Regular use a cane for mobility was reported. Lumbar spine DDD with radiculopathy was diagnosed. In an April 2012 rating action, service connection was established for radiculopathy of the right and left lower extremities, related to the disability of the lumbar spine, for which separate ratings of 10 percent (right) and 20 percent (left) were assigned, effective from July 2005. VA outpatient/CAPRI records current to March 2012 were also reviewed revealing on-going complaints and treatment related to the low back. Analysis The Veteran contends the currently assigned 20 percent evaluation does not accurately reflect the severity of his lumbar spine disability. For the entirety of the appeal period, his low back disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3. 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 considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). More recently, the Court held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The criteria for evaluation are found in the General Rating Formula for Diseases and Injuries of the Spine which applies to the following diagnostic codes: vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), spondylolisthesis or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), degenerative arthritis of the spine (DC 5242), and intervertebral disc syndrome (DC 5243). 38 C.F.R. § 4.71a. A note associated with the rating criteria instructs that intervertebral disc syndrome evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, whichever method results in the higher evaluation. The General Rating Formula for Diseases and Injuries of the Spine assigns evaluations with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by the residuals of the injury or disease. The formula provides that a 20 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, a 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. A 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine at 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. Note 1 following the general rating formula for diseases and injuries of the spine specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate Diagnostic Code. Note 2 provides that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. See also Plate V. 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 combined range of motion 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. Under the Diagnostic Code 5243, a 20 percent evaluation is assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent evaluation is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent evaluation is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. For purposes of evaluations under diagnostic code 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. Id. at Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id at Note (2). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5003, 5010. For traumatic arthritis, DC 5010 directs that the evaluation of arthritis be conducted under DC 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5010. In the absence of limitation of motion, X- ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003, Note 1. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In addition, in evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement and weakness. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). On a schedular basis, a review of the evidence pertinent to the appeal period does not reflect that the Veteran's service-connected disability of the lumbar spine is manifested by symptoms warranting a rating in excess of 20 percent (other than the separate ratings provided for right and left lower extremity radiculopathy which have not been appealed to the Board). Specifically, absent any evidence forward flexion of the lumbar spine limited to 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; or incapacitating episodes of IVDS having a total duration of at least 6 weeks during any 12-month period., an evaluation in excess of 20 percent is not warranted for any portion of the appeal period. Having reviewed 5 VA examination reports dated from 2005 and 2012, as well as VA and private medical records it is clear that the Veteran has DJD and/or DDD, as well as limitation of motion of the spine. However, at no time has flexion of the Veteran's lumbar spine been shown as limited to 30 degrees or less, nor have the Veteran or his representative identified any such evidence. The Veteran himself has not specifically described lumbar flexion of 30 degrees or less. Furthermore, no clinical records or examination reports reveal evidence of favorable ankylosis of the entire thoracolumbar spine at any time during the appeal period. To the extent the Veteran argues otherwise, the Board places greater probative weight to the clinical finding by VA physicians who have measured forward flexion with use of a goniometer which is more accurate than a lay observation. The Board has also considered whether separate or increased evaluations are warranted based upon a showing of neurological symptomatology related to the lumbar spine. In this regard, the file contains lay and clinical evidence of neurological symptoms affecting the lower extremities related to the low back disability for which service connection has already been established. The Veteran has been assigned a 10 percent rating for right lower extremity radiculopathy, and a 20 percent rating for left lower extremity radiculopathy. The Veteran has not appealed these disability determinations, by which service connection was granted in an April 2012 RO rating decision. The Board finds that there is no credible evidence of any additional neurologic impairment related to the thoracolumbar spine disability. The Veteran has reported symptoms of urinary frequency and urgency, but VA examiners in 2007 and 2010 found that such symptomatology was unrelated to the Veteran's back disability. As indicated in the Introduction section, the Veteran has been assigned a schedular rating for chronic prostatitis symptoms. Accordingly, there is no basis for the assignment of a separate or compensable evaluation for additional neurological manifestations other than right and left lower extremity radiculopathy. To the extent the Veteran argues otherwise, the Board places greater probative weight to the opinions of VA examiners who have greater training and expertise than the Veteran in diagnosing neurologic impairment stemming from a back disability. The Board also considers whether a higher rating may be assigned under Diagnostic Code 5243, based on incapacitating episodes associated with IVDS. The combined rating for the Veteran's lumbar spine disability is 50 percent after combining the disability ratings (20 percent for the orthopedic manifestations, 20 percent for left lower extremity radiculopathy and 10 percent for right lower extremity radiculopathy) under 38 C.F.R. § 4.25 and adding the bilateral factor per 38 C.F.R. § 4.26. Thus, under the alternative criteria for evaluation incapacitating episodes of IVDS, a higher rating would be 60 percent. In his June 2011 testimony, the Veteran stated that he had experienced incapacitating episodes for 8 to 10 weeks a year (p. 6). Upon VA examination of the spine conducted in January 2012, he reported experiencing severe episodes every 4 to 6 weeks, lasting up to 10 days and requiring bed rest for 7 days, during which times he took Advil. However, the applicable regulation makes it clear that lay evidence alone is not sufficient to establish that the rating criteria for the lumbar spine as pertains to IVDS/incapacitating episodes have been met; there must be evidence provided from a physician documenting treatment/a requirement of bedrest. Essentially, there is no indication in the clinical evidence of any incapacitating episodes requiring bed rest prescribed by a physician and/or treatment by a physician occurring in the duration and frequency required for the assignment of a 60 percent evaluation. The Veteran has similarly been unable to recall actual dates of his reported episodes of incapacitation, either in his hearing testimony or upon VA examinations (see for instance April 2010 VA examination report). Throughout the appeal period, the evidence reflects the Veteran has consistently complained of pain and limitation of function associated with his lumbar spine disability and has described restriction of activities, such as standing, sitting, and weight bearing. VA examination reports document evidence of pain on motion and the Veteran has provided lay evidence of pain productive of functional impairment. Although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the rating schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). The Board finds that the currently assigned 20 percent evaluation contemplates the effects of the Veteran's manifestations of pain, weakness, and fatigue on activity and motion. The VA examiners in August 2005, May 2007, January 2012 and March 2012 found no additional limitation of motion due to weakness, fatigability or incoordination on repetitive testing. The VA examiner in April 2010 described a decrease of flexion from 51 degrees to 42 degrees due to pain, which still falls well short of the criteria for limitation of motion of 30 degrees or less. Therefore, an increased evaluation based upon pain and functional impairment is not warranted for any portion of the appeal period. 38 C.F.R. § 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242; DeLuca v. Brown, 8 Vet. App. 202 (1995). Having considered the concept of staged ratings in this case as discussed in the Hart case, supra, the Board concludes that entitlement to a disability rating in excess of 20 percent is not warranted for the portion of the appeal period extending from July 14, 2005, when the increased rating claim was filed. In so holding, the Board finds that the Veteran's complaints of severe low back pain and limitations are credible and consistent with the evidentiary record, to include the fact that he holds separate ratings for neurologic impairment and a TDIU rating. To the extent that he argues entitlement to a higher schedular rating for his low back disability, the Board places greater probative weight to the clinical findings of medical professionals who have greater expertise and training than the Veteran in evaluating the nature and severity of orthopedic and neurologic manifestations of thoracolumbar spine disease. The Board has considered the provisions of 38 C.F.R. §§ 4.3 and 4.7, and the benefit-of-the-doubt doctrine, but they are not applicable to the facts of this case. Gilbert, 1 Vet. App. 49, 53-56 (1990); see 38 U.S.C.A. § 5107(b) (West 2002). Extra-Schedular Considerations and TDIU The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted in Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or 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. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 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. The Veteran's manifestations of his service-connected low back disability are contemplated by the rating criteria. Here, the rating criteria consider factors such as pain, limitation of motion, muscle spasm, guarding, abnormal gait, abnormal spinal contour, ankylosis, neurologic impairment and the frequency and duration of incapacitating IVDS episodes. The currently assigned ratings (20 percent for the orthopedic manifestations, 20 percent for left lower extremity radiculopathy and 10 percent for right lower extremity radiculopathy) reasonably describe the Veteran's disability level and symptomatology and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. In short, for the reasons already set forth above, the rating criteria contemplate not only his symptoms but the severity of his low back disability as is reflected by the currently assigned ratings. Therefore, as the assigned 20 percent rating for the orthopedic manifestations is adequate, analysis of the next step of whether an exceptional disability picture is presented is not for consideration and referral for extraschedular consideration is not warranted. The Court has held that a request for entitlement to a TDIU, whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case the Veteran formally raised a TDIU claim and it was granted in a Board decision issued in January 2012, and implemented in a February 2012 rating action. Hence, no further consideration of this matter is necessary. ORDER For the portion of the appeal period extending from July 14, 2005, an evaluation in excess of 20 percent for a disability of the lumbar spine is denied. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs