Citation Nr: 1406772 Decision Date: 02/14/14 Archive Date: 02/24/14 DOCKET NO. 04-41 615 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California THE ISSUES 1. Entitlement to an effective date earlier than April 4, 2005 for the grant of service connection for Tourette's syndrome. 2. Entitlement to an effective date earlier than July 22, 2011 for the grant of service connection for major depressive disorder. 3. Entitlement to service connection for asthma. 4. Entitlement to an initial rating in excess of 30 percent for major depressive disorder. 5. Entitlement to an initial rating in excess of 10 percent for right knee degenerative arthritis. 6. Entitlement to an initial rating in excess of 20 percent for left knee degenerative joint disease prior to February 13, 2007 and since May 1, 2007. 7. Entitlement to an initial rating in excess of 20 percent for a neck disability. 8. Entitlement to an initial rating in excess of 10 percent for a back disability. 9. Entitlement to a compensable rating for dermatographism. 10. Entitlement to an initial rating in excess of 10 percent for left foot neuropathy. 11. Entitlement to service connection for a neurologic disability of the right lower extremity other than lumbar radiculopathy. 12. Entitlement to service connection for a neurologic disability of the bilateral upper extremities. 13. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant (the Veteran) is represented by: Karl A. Kazmierczak, Attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from July 1981 to March 1990. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the RO in Oakland, California dated in May 2006, November 2008, October 2010, June 2011, and January 2013. In September 2011, the Board remanded the issues of entitlement to an effective date earlier than April 4, 2005 for the grant of service connection for Tourette's syndrome and entitlement to a compensable rating for dermatographism, to afford the Veteran a requested Board hearing. The Veteran subsequently withdrew his hearing request in writing, indicating that he no longer wished to attend a hearing. The Board acknowledges that the Veteran did not specifically disagree with the effective date for the grant of service connection for major depressive disorder; however, the RO listed the issue on the September 2013 statement of the case. The Veteran subsequently (VA Form 9) asserted that an earlier effective date was warranted and checked the box indicating that he was appealing all issues listed on the statement of the case. In Percy v. Shinseki, 23 Vet. App. 37 (2009), the United States Court of Appeals for Veterans Claims (Veterans Court) held that by treating an issue as if it were part of a veteran's appeal, the RO waived any objections it might have had as to procedural deficiencies in the appeal. In reviewing this case, the Board has not only reviewed the physical claims file, but has also reviewed the electronic file on the "Virtual VA" system and the Veterans Benefits Management System (VBMS) to insure a total review of the evidence. The issues of entitlement to service connection for neurologic disabilities of the bilateral upper extremities and right lower extremity, entitlement to an increased initial rating for left foot neuropathy, entitlement to an increased rating for dermatographism, and entitlement to TDIU are addressed in the REMAND below and are therein REMANDED to the Department of Veterans Affairs Regional Office. The issue of entitlement to service connection for bladder incontinence claimed due to the service-connected back disability has not been adjudicated by the RO, but is reasonably raised by the record (see June 2009 report of Craig N. Bash, M.D.). The issue is therefore referred to the RO for appropriate action. See 38 C.F.R. §19.9(b)(2013). FINDINGS OF FACT 1. The earliest date of a pending claim for service connection for Tourette's Syndrome is April 4, 2005. 2. The date of receipt of the claim for service connection for Tourette's Syndrome is later than the date entitlement arose. 3. The earliest date of a pending claim for service connection for major depressive disorder is July 22, 2011. 4. The date of receipt of the claim for service connection for major depressive disorder is later than the date entitlement arose. 5. The Veteran's asthma is presumed to have been incurred in active service. 6. For the entire period of the claim on appeal, the Veteran's major depressive disorder has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 7. For the entire period of the claim on appeal, the Veteran's right knee disability has been manifested by arthritis with painful and weakened motion, with extension and flexion each limited to a noncompensable degree; there was no lateral instability or recurrent subluxation. 8. For the entire period of the claim on appeal, the Veteran's left knee disability has been manifested by arthritis with painful and weakened motion, with flexion limited to a noncompensable degree and with extension limited to at most 18 degrees; there was no lateral instability or recurrent subluxation or symptomatic removed semilunar cartilage. 9. From June 16, 2009 to November 18, 2010, the Veteran's neck disability was manifested by forward flexion of the cervical spine to 15 degrees or less, without ankylosis. 10. Prior to June 16, 2009 and since November 18, 2010, the Veteran's neck disability has been manifested by forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. 11. From April 12, 2007 to November 18, 2010, the Veteran's back disability was manifested by forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees. 12. Prior to April 12, 2007 and since November 18, 2010, the Veteran's back disability has been manifested by slight limitation of motion with forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than April 4, 2005 for the grant of service connection for Tourette's Syndrome are not met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5110, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.151, 3.156(c), 3.155, 3.159, 3.400 (2013). 2. The criteria for an effective date earlier than July 22, 2011 for the grant of service connection for major depressive disorder are not met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5110, 7104; 38 C.F.R. §§ 3.102, 3.151, 3.156(c), 3.155, 3.159, 3.400. 3. The criteria for service connection for asthma are met. 38 U.S.C.A. §§ 1131, 1153, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.310 (2013). 4. The criteria for a disability rating higher than 30 percent for major depressive disorder have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9434 (2013). 5. The criteria for a disability rating higher than 10 percent for a right knee disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260 (2013). 6. Prior to February 13, 2007 and since May 1, 2007, the criteria for a disability rating higher than 20 percent for limitation of motion of the left knee have not been met for any portion of those periods. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260. 7. From June 16, 2009 to November 18, 2010, the criteria for a disability rating of 30 percent for a neck disability were met; the criteria for a disability rating higher than 30 percent were not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2013). 8. Prior to June 16, 2009 and since November 18, 2010, the criteria for a disability rating higher than 20 percent for a neck disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 9. From April 12, 2007 to November 18, 2010, the criteria for a 20 percent rating for a back disability were met; the criteria for a disability rating higher than 20 percent were not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5292, 5295, 5237 (2003-2013). 10. Prior to April 12, 2007 and since November 18, 2010, the criteria for a disability rating higher than 10 percent for a back disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5292, 5295, 5237 (2003-2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Effective Date Claims The Veteran is seeking earlier effective dates for service connection for Tourette's syndrome and major depressive disorder. As noted above, the Veteran did not specifically disagree with the effective date for major depressive disorder and he has not identified the effective date he believes is warranted for that disability. Regarding Tourette's syndrome, the Veteran maintains that the grant of service connection should be effective as of March 1990. After a review of all of the evidence, the Board finds that a preponderance of the evidence is against an effective date for the grant of service connection for Tourette's Syndrome of March 1990. The Veteran filed a claim of entitlement to service connection for Tourette's Syndrome in October 1990, within one year of service separation. That claim was denied in an August 1991 rating decision. Notice of the decision was mailed to the Veteran's address of record in August 1991. The August 14, 1991 cover letter indicates in the last paragraph that VA Form 1-4107 was enclosed and sent to the Veteran. This form explained the Veteran's procedural and appeal rights. The Veteran asserts that he was never notified of his right to appeal the decision. There is a presumption of regularity under which it is presumed that Government officials have properly discharged their official duties. Mindenhall v. Brown, 7 Vet. App. 271 (1994). Clear evidence to the contrary is required to rebut the presumption of regularity. See Ashley v. Derwinski, 2 Vet. App. 307 (1992), citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926). A claimant's mere statement of nonreceipt is insufficient for that purpose. See Butler v. Principi, 244 F.3d 1337, 1340 (Fed.Cir.2001). The Veteran has presented on his assertion of nonreceipt. The Board finds that no clear evidence to the contrary has been presented with which to rebut the presumption of regularity. It is therefore presumed that notice of the Veteran's appellate rights were mailed to him along with the rating decision. Accordingly, the one year time limit in which to initiate an appeal began running on August 14, 1991. The Veteran does not contend and the record does not show that the Veteran filed a Notice of Disagreement, or a document which might be construed as a Notice of Disagreement within one year of the August 14, 1991 letter. 38 C.F.R. §§ 20.200, 20.302 (2013). No evidence was received from the Veteran until he filed a claim in June 2003. 38 C.F.R. § 3.156(b). As the August 1991 rating decision was not appealed, and as no other impediments to finality are present, the Board finds that the decision became final at the expiration of the appeal period. 38 U.S.C.A. § 7105; 38 C.F.R. § 38 C.F.R. § 20.1103. The Veteran filed another set of service connection claims in June 2003, but limited his claims to back, leg, and hip pain. Accordingly, a claim of entitlement to service connection for Tourette's syndrome was not reasonably raised. The next submission that can be interpreted as a claim of entitlement to service connection for Tourette's syndrome comes in the form of the April 2005 claim. The Veteran's essential argument regarding an earlier effective date for Tourette's syndrome centers on the fact that he filed a claim in 1990 and that service connection was ultimately granted for Tourette's syndrome. However, the finality of the 1990 claim forecloses any attempt to establish an effective date based on it. In short, the Veteran had recourse at the time of the 1990 decision, which was to appeal that decision. An attempt to assign an effective date based on a final decision is without merit and must be dismissed as a freestanding claim for an earlier effective date. Leonard v. Nicholson, 405 F.3d 1333 (Fed. Cir. 2005); Rudd v. Nicholson, 20 Vet. App. 296 (Fed. Cir. 2006). The Veteran has also asserted that there was error in the August 1991 rating decision. While he has not explicitly asserted that there was clear and unmistakable error (CUE), the Board has considered whether such a claim has been reasonably raised. The Board finds that a CUE claim is not reasonably raised as the Veteran's descriptions of errors in the August 1991 decision, even if accepted as true, cannot be considered CUE. An assertion that the evidence was not properly weighed or evaluated cannot constitute CUE. An allegation of CUE must specifically state what error occurred and how the outcome would have been manifestly different. Where a claimant fails to reasonably raise a CUE claim as set forth above, there is no requirement to address the merits of the issue. Fugo v. Brown, 6 Vet. App. 40, 45 (1993). In other words, if the error alleged is not the type of error that, if true, would be CUE on its face; or if the claimant is only asserting disagreement with how the RO evaluated the facts before it; or if the claimant has only alleged a failure on the part of VA to fulfill its duty to assist; or if the claimant has not expressed with specificity how the application of cited laws and regulations would dictate a manifestly different result, then the claim should be denied or the appeal to the Board dismissed. Simmons v. Principi, 17 Vet. App. 104 (2003). The Veteran's assertion of error is that the August 1991 decision was made on incomplete information (citing the VA examination). See June 2006 correspondence. In essence, the Veteran has asserted a failure in the duty to assist him in developing his claim in August 1991. This is manifestly not CUE even if true. A question as to the adequacy of a VA medical examination is not a valid basis for CUE. See Elkins v. Brown, 8 Vet. App. 391, 396 (1995), Caffrey v. Brown, 6 Vet App. 377, 384 (1994). A question as to the adequacy of development of the record is also not a valid basis for CUE in a prior adjudication. Elkins, 8 Vet. App. at 396, Caffrey, 6 Vet App. at 384. Thus, as the Veteran's allegations would not constitute CUE even if conceded, to the extent he is deemed to have raised an allegation of CUE, such must be dismissed without prejudice. In sum, the Board concludes that a preponderance of the evidence is against an effective date for the grant of service connection for Tourette's syndrome earlier than April 4, 2005. Regarding the effective date for major depressive disorder, as noted above, this appeal arose essentially from an error of the RO in preparation of the statement of the case. The Veteran's notice of disagreement does not mention the effective date for the grant of service connection for major depressive disorder. Other than agreeing with the statement of the case that the issue was on appeal, the Veteran and his attorney have offered no specific argument as to what should be the proper effective date for the grant of service connection for major depressive disorder. The Board finds that, prior to the July 22, 2011 correspondence, which specifically identified a "NEW" claim for major depressive disorder, and which identified an initial diagnosis in March 2009, there is no correspondence from the Veteran that can reasonably be interpreted as a claim of entitlement to service connection for major depressive disorder. The Board finds that VA treatment records and/or examination reports, to the extent that they establish an earlier onset of major depressive disorder, cannot serve as a claim (formal or informal) for service connection for major depressive disorder. Generally, the mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit. Criswell v. Nicholson, 20 Vet. App. 501 (2006); 38 C.F.R. § 3.155(a). Once a formal claim for pension or compensation has been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability is not compensable in degree, receipt of a report of VA examination will be accepted as an informal claim for increased benefits or an informal claim to reopen. The date of examination will be accepted as the date of receipt of the claim. See 38 C.F.R. § 3.157(b). This applies only when a claim specifying the benefit sought is received within one year of the date of the VA examination report. Id; see also Pacheco v. Shinseki, No. 12-0389, slip op. at 5 (U.S. Vet. App. Jan. 16, 2014). The Veteran's claim for service connection for depression was filed in July 2011, more than one year after the March 2009 diagnosis. The Board finds that the March 2009 VA examination report cannot serve as an informal claim for service connection for depression. The controlling statute and regulation provide that the effective date for a grant of service connection is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Here, there is no dispute. The Veteran has asserted that entitlement to service connection for both Tourette's Syndrome and major depressive disorder arose prior to the date of those respective claims, and this assertion is supported by the record; therefore, regarding Tourette's Syndrome, the date of claim, April 4, 2005, is the later of the two dates and is the appropriate effective date. Regarding major depressive disorder, the date of claim, July 22, 2011, is the later of the two dates and is the appropriate effective date. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). The pertinent legal authority governing effective dates is clear and specific, and the Board is bound by such authority. See 38 U.S.C.A. § 7104(c) (West 2002); 38 C.F.R. § 20.101(a) (2013). As there is no legal basis for assignment of any earlier effective date than April 4, 2005 for Tourette's Syndrome and July 22, 2011 for major depressive disorder, the Board finds that the claimed earlier effective dates are not warranted. Where, as here, the law, and not the evidence, is dispositive, the appeal must be denied as without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Service Connection for Asthma The Veteran asserts that he has asthma which predated service and was aggravated by service. After a review of all of the evidence, the Board finds that evidence establishing incurrence of asthma in service is in relative equipoise with the evidence against the claim. The evidence demonstrates that the Veteran has a current disability of asthma. The Veteran was examined at enlistment in July 1981 and was found to be clinically normal regarding the lungs and chest. There is no report of medical history taken at that time. As no defect was noted on examination at enlistment, the presumption that the Veteran's respiratory system was in sound condition has attached in this case. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b); see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Patrick v. Shinseki, 668 F.3d 1325, 1329 (Fed. Cir. 2011). The service treatment records reveal that the Veteran was treated in September 1986 for complaint of occasional wheezing when working around cement dust. A questioned diagnosis of allergies was noted. An October 1986 consultation report reveals complaints of spasms of coughing about midnight each night. The diagnosis was bronchospastic phenomenon. A service separation examination was not conducted. Dental patient reports of medical history are of record from September 1985, December 1986, and December 1987. In September 1985, the Veteran reported a history of asthma 5 years prior. In December 1986 and December 1987, the Veteran reported a history of asthma as a child "only." The Veteran was evaluated in June 2008 by a VA contract physician. The Veteran reported that, when he entered service, he had not had an asthma attack for 7 years. The Veteran reported that he experienced 30 exacerbations of reactive airway disease in service. After service, the frequency of attacks were reported to be between 1 and 1.5 per month. The examiner diagnosed asthma, stable on medications (Albuterol). The examiner did not provide an opinion regarding nexus or aggravation. The Veteran provided a private opinion dated in June 2009, which was based on service treatment records provided by the Veteran. The private physician noted episodes of reactive airway disease (citing specifically the October 2, 1986 report) and found these reports to be consistent with asthma in service. It was the opinion of the private physician that asthma should be assigned a service-connected rating. The Veteran was provided another examination in March 2010 by the same VA physician as conducted the June 2008 evaluation. The examiner commented that he could not find significant records cited by the RO and that the claims file was in disarray and was out of order, and that the enlistment examination had an incorrect date on it. The VA examiner reviewed the results of his prior examination with the Veteran and they essentially agreed that the Veteran had childhood asthma prior to service, was never hospitalized prior to service, but when he went into service, he had multiple asthma attacks. The diagnosis was bronchial asthma, stable on medications. No opinion was rendered concerning causation or aggravation. Regarding the examiner's difficulty locating records, the Board notes that the enlistment examination is dated July 23, 1981, which is the actual date of enlistment. It is unclear what was improper about this date. It is also unclear what the examiner meant by the claim file being in disarray. Moreover, the June 2009 private examination report cited by the examiner as missing from the claims file is filed below the examination report and was apparently in the claims file at the time of the examination. The Board concludes that the presumption of soundness is not rebutted on this record. While the Veteran acknowledges that he had asthma as a child, the Board has found that he was in sound condition at service entry. Accordingly, the case is one of direct service connection and not aggravation. The only medical opinion regarding the etiology of asthma in this case is that of the Veteran's private physician. The Board finds that this opinion is conclusively stated and is essentially consistent with the record, and that there is no basis to find it inadequate. Accordingly, the Board finds that it is probative evidence linking current asthma to service. With resolution of all reasonable doubt in the Veteran's favor, the Board concludes that currently diagnosed asthma is related to service and service connection for asthma is therefore warranted. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). III. Increased Rating -- Major Depressive Disorder In a January 2013 rating decision, the RO granted service connection for major depressive disorder and assigned a 30 percent initial rating pursuant to Diagnostic Code 9434, effective July 22, 2011. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: a 10 percent rating where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication; a 30 percent rating if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events); a 50 percent rating if 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; a 70 percent rating with 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 work-like setting); and inability to establish and maintain effective relationships; and a 100 percent rating for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130, Diagnostic Code 9411. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). After a review of all of the evidence, the Board finds that a preponderance of the evidence is against any rating in excess of 30 percent for major depressive disorder. The primary evidence pertinent to the period under consideration comes from the report of VA examination in in October 2012. The examiner diagnosed major depressive disorder, which he categorized as mild. The Veteran was noted to be functioning at a generally satisfactory level with regard to routine behavior and self care. The examiner noted that there was evidence of occasional decreases in functioning due to depression, anxiety and chronic sleep impairment. The examiner found that the Veteran did not endorse weekly panic attacks, difficulty understanding complex commands, impaired memory, impaired abstract thinking, or significant difficulty establishing and maintaining relationships. The examiner acknowledged some pattern of poor judgment based on an incident in March 2009 (prior to the period on appeal) when the Veteran was hospitalized for attempting to insert a wire into his urethra. Also probative regarding the Veteran's level of functioning during the period on appeal, the October 2012 VA examiner assigned a GAF score of 62. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic And Statistical Manual Of Mental Disorders, 4th ed. (DSM-IV) at 32). A GAF score of 61-70 indicates mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The Board notes that the findings of the October 2012 examiner regarding mild symptoms and a GAF score of 62 were substantiated by specific testing conducted by the examiner in order to gauge the Veteran's level of depression. This testing indicated mild symptoms of depression over the past two weeks. Symptoms included but were not limited to feeling sad much of the time, feeling more discouraged about the future, loss of pleasure, guilt, worthless, decreased energy, feeling tired, or fatigue. Also significant, the examiner found that the Veteran's ability to conduct activities of daily life was fair. While the Veteran reported disturbed sleep and checking the security of his home 3-4 times before going to bed, chronic sleep impairment and anxiety are entirely consistent with a 30 percent rating. The Board acknowledges the Veteran's report to the examiner that he felt sad more days than not and was unable to engage in activities he used to enjoy due to physical and financial limitations. He also described psychomotor retardation or agitation, fatigue, feelings of worthlessness, and guilt. The Veteran had been upset about finances, extended family issues, and his medical condition. Again, symptoms such as a depressed mood and anxiety are consistent with a 30 percent rating, as are intermittent periods of inability to perform occupational tasks. Based on the explicit findings of the October 2012 examiner that the Veteran's major depressive disorder is mild and the symptom examples for the 50 percent rating level are not demonstrated in this case, the Board finds that a rating in excess of 30 percent for major depressive disorder is not warranted. The Board also emphasizes the finding of the October 2012 examiner that the Veteran was functioning at a generally satisfactory level with regard to routine behavior and self care, and that there was evidence of occasional decreases in functioning. This is consistent with the structure of the rating schedule at the 30 percent level. Notably, a crucial distinction between the 30 percent and 50 percent rating criteria is that rating criteria for the 30 percent level specify intermittent or occasional symptomatology. The rating criteria for the 50 percent level appear to contemplate a level of functional impairment that is more constant in nature. The Veteran's attorney asserts that a GAF score of 55 was assigned in a March 2009 hospital discharge summary following an incident of the Veteran having attempted to insert a wire into his urethra. A GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). The Board notes that, while it has considered all of the evidence in deciding this claim, the evidence pertinent to the period on appeal carries greater probative weight with regard to the Veteran's current condition and rating than does evidence generated more than 2 years prior to the receipt of the current claim. While the Board has not found that this evidence is irrelevant, it is not as probative of the Veteran's current level of impairment as the October 2012 report, which includes a GAF score of 62. To summarize the Board's findings, during the entire period of this appeal, the Veteran's major depressive disorder has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). There is no portion of the period on appeal during which the Veteran's symptomatology has more closely approximated the criteria for any higher rating. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. IV. Increased Rating - Bilateral Knees The current appeal as to the left knee arises from a claim received at the RO in January 2007. In a November 2008 rating decision, the RO granted service connection for a left knee disability (degenerative joint disease) and assigned a 20 percent rating pursuant to Diagnostic Code 5261, effective January 18, 2007. In a January 2013 rating decision, the RO granted a temporary 100 percent rating for left knee surgical convalescence, effective February 13, 2007, with a 20 percent rating assigned pursuant to Diagnostic Code 5261, effective May 1, 2007. The current appeal as to the right knee arises from a claim received at the RO in July 2009. In an October 2010 rating decision, the RO granted service connection for a right knee disability (degenerative arthritis) and assigned a 10 percent disability rating pursuant to Diagnostic Code 5010, effective July 6, 2009. Diagnostic Code 5010 is used to rate arthritis due to trauma, but it simply redirects to rate in accordance with degenerative arthritis (Diagnostic Code 5003), which in turn rates on the basis of limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Ratings for limitation of knee motion are addressed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 addresses limitation of flexion of the knee. Under that code, a 30 percent rating is for application were flexion is limited to 15 degrees; a 20 percent rating is for application where flexion is limited to 30 degrees; a 10 percent rating is for application where flexion is limited to 45 degrees; a 0 percent rating is for application where flexion limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 addresses limitation of extension of the knee. Under that code, a 50 percent rating is for application where extension is limited to 45 degrees; a 40 percent rating is for application where extension is limited to 30 degrees; a 30 percent rating is for application where extension is limited to 20 degrees; a 20 percent rating is for application where extension is limited to 15 degrees; a 10 percent rating is for application where extension is limited to 10 degrees; a 0 percent rating is for application where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5256 governs ankylosis (complete bony fixation) of the knee, which is neither asserted nor shown here with respect to either knee. Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of the knee. Under that code, a 30 percent rating is for application where subluxation or lateral instability is severe. A 20 percent rating is for application where subluxation or lateral instability is moderate. A 10 percent rating is for application where subluxation or lateral instability is slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board notes that the criteria under Diagnostic Codes 5257, 5260, and 5261 are not considered to be overlapping, and therefore separate ratings can be assigned where appropriate symptomatology is shown. The current 10 percent rating for the right knee under Diagnostic Codes 5010, 5003 is assigned due to X-ray evidence of arthritis with motion (flexion and extension) which is not limited to a compensable degree. The current 20 percent rating for the left knee under Diagnostic Code 5261 is assigned due to limited extension, but with flexion that is not limited to a compensable degree. After a review of all of the evidence, the Board finds that a preponderance of the evidence is against the assignment of any higher rating based on limited motion of either knee. Regarding measurements of flexion, each knee exceeds the degree of limited flexion specified for the minimum compensable rating. The report of a VA examination in January 2006 reveals full range of motion of the knees from 0 to 140 degrees. When examined in February 2008 (March 2008 report), with three repetitions of active and passive movements, flexion was measured to 135 degrees on the right and 95 degrees on the left. A private physician, Craig N. Bash, M.D., who examined the Veteran in June 2009 found that the right knee had full range of motion. There was no comment as to the left knee. The report of a VA examination in June 2010 reveals that right knee flexion was measured to 110 degrees. After three repetitions of movement, there was no additional loss of right knee flexion. There was no pain, fatigue, weakness, lack of endurance, or loss of coordination. Left knee flexion was measured to 90 degrees. After three repetitions of movement, there was no additional loss of left knee flexion. There was pain, fatigue, weakness, and lack of endurance, but no loss of coordination. Pain was the most significant factor. The report of a VA examination in September 2010 reveals that right knee flexion was measured to 80 degrees. After three trials, it was also 80 degrees. Motion was accompanied by increased pain, fatigue, weakness, and lack of endurance. Left knee flexion was measured to 80 degrees. After three trials it was also 80 degrees. Motion was accompanied by increased pain, fatigue, weakness, and lack of endurance. The report of a VA examination in November 2012 reveals that right knee flexion was measured to 130 degrees with no objective signs of painful motion. After 3 repetitions, right knee flexion decreased to 110 degrees. Left knee flexion was measured to 130 degrees with no objective evidence of painful motion. After 3 repetitions, flexion decreased to 110 degrees. Thus, in no instance has there been measured range of flexion of either knee that is limited to 45 degrees. Accordingly, a compensable rating is not warranted for either knee on the basis of limitation of flexion under Diagnostic Code 5260. Regarding measurements of extension, with only 1 exception, measurements have been normal. The report of a VA examination in January 2006 reveals full range of motion of the knees from 0 to 140 degrees. The report of a VA examination in February 2008 reveals that, with three repetitions of active and passive movements, extension was to 0 degrees on the right and 18 degrees on the left. As noted above, a private physician in June 2009 found that the right knee had full range of motion. There was no comment as to the left knee. The report of VA examination in June 2010 reveals that right knee extension was 0 degrees; after three repetitions of movement, there was no additional loss of right knee extension; there was no pain, fatigue, weakness, lack of endurance, or loss of coordination. Left knee extension was 0 degrees; after three repetitions of movement, there was no additional loss of left knee extension; there was pain, fatigue, weakness, and lack of endurance, but no loss of coordination; pain was the most significant factor. The report of VA examination in September 2010 reveals 0 degrees of left knee extension. After three trials it was also 0 degrees. There was increased pain, fatigue, weakness, and lack of endurance. Right knee extension was to 0 degrees. After three trials, it was also to 0 degrees. There was increased pain, fatigue, weakness, and lack of endurance. When examined in November 2012, there was no limitation of extension. After 3 repetitions, right knee extension remained at 0 degrees. Left knee extension was also normal. After 3 repetitions, extension remained normal. Thus the degree of limitation of extension required for the current 20 percent rating has only been demonstrated on one occasion. At all other times, extension of each knee has been normal. Thus, a compensable rating is not warranted for the right knee on the basis of limited extension, under Diagnostic Code 5261, and a rating in excess of the 20 percent already assigned under Diagnostic Code 5261 is not warranted for the left knee. The evidence clearly establishes that both of the Veteran's knees are painful. Pain on motion must be considered in determining limitation of motion, as must other orthopedic factors such as weakness, fatigue, and incoordination. The Veteran wrote in November 2007 that it was difficult for him to get dressed and climbing was problematic. He reported that his left knee folded out from under him the other day when an elevator stopped abruptly. The Veteran's wife wrote that the Veteran has fallen at least four times while walking or negotiating stairs due to his knees buckling without warning. One of these falls required a trip to the E.R. on May 14, 2010. In the notice of disagreement, the Veteran's attorney asserted that, due to his pain (nonspecific), the Veteran cannot use the toilet on his own and cannot dress himself. His social life is no longer existent and any recreational activities he would ordinarily enjoy are no longer an option. He is unable to drive. He described his pain as 8 out of 10 when at rest and worse when he engages in any activities. In addition, the Board acknowledges that the Veteran experiences episodes of give-way weakness and "buckling." The Board interprets this somewhat imprecise term as the equivalent of weakness, or a sudden inability to support weight on the knee. The Veteran has also reported fatigue, and lack of endurance. The report of VA examination in February 2008 reveals complaints of pain with give-way weakness and burning, as well as stiffness, popping, and swelling. The Board interprets give-way weakness as the equivalent of buckling. Sitting, standing, bending, stooping, pushing, pulling, lifting, overhead work, kneeling, crawling, squatting, and walking were found to cause flare ups of pain. The reduced joint motion was found to be due to pain, fatigue, and lack of endurance, with pain being the most significant factor. A VA examination in June 2010 reveals the Veteran's report that he was limited in his activities of daily living. He reported that he could not walk more than fifteen to twenty minutes and that he has difficulty going up and down stairs, especially going down stairs, and that driving leads to stiffness, especially after one-half hour. The Veteran reported moderate to severe pain in the left knee, lack of endurance, and weakness as a result of the pain. Sitting, standing, bending, stooping, lifting, overhead work, kneeling, crawling, and squatting, can cause the Veteran to have a flareup of pain. These flareups of pain can be severe and can last for two days, depending on the activity that caused the flareup. These flareups can occur 2 times a month. The Veteran reported that he uses a brace to help with ambulation and has for 3 years. He stated he can walk 3/4 of a mile (20 minutes), before he has an increase in his pain. He reported 6-10 incapacitating episodes in the prior year. The Veteran noted that this condition affects his activities of daily living, the performance of his occupational duties, recreational activities, and driving ability. An examination in September 2010 reveals the chief complaint of right knee pain. The Veteran described the pain as being sharp, throbbing, burning, and dull, with give-way weakness, stiffness, numbness, tingling, popping, and swelling. The pain was constant in nature. On a scale of 1 to 10, where 10 is severe, he rated the pain at 8 when he is at rest. Sitting, standing, bending, stooping, lifting, overhead work, kneeling, crawling, squatting, and walking can cause the Veteran to have a flare-ups of pain. These flare-ups are severe in degree and can last for several days, depending on the activity that caused the flare. These flare-ups occur twice a month. He has to stop and rest until the flare-up has passed. He reported that he can walk with pain approximately 3/4 of a mile or about 20 minutes before it becomes too painful to continue. The swelling occurs maybe once every two months and may last for several days and seems to be triggered by activities including stair climbing and walking. Activities of daily living are limited. He is mainly limited to activities around the house including vacuuming and cleaning dishes. He is unable to do any yard work most of the time. He has avoided any recreational activities including ball games. He can only walk short distances. His recreational activities are greatly impacted. He can no longer enjoy any outdoor activities and some indoor activities. His driving ability is impacted when he has to drive longer then 45 minutes at a time. A VA examination in November 2012 reveals the Veteran's complaint that his knees buckle at times. He does not climb ladders anymore due to fear of buckling, causing him to lose balance. He can walk only about 1/2 mile. He can stand only about 30 minutes. His knees limit him from heavy lifting, squatting, climbing, walking long distances and standing for long periods of time. The Veteran's knees render him unable to secure and maintain substantially gainful employment as a heating/air conditioning boiler operator. His knee pain and limitation of range of motion physically limit him from performing the physical labor of his profession. Balanced against the Veteran's reports of weakness are clinical findings which consistently demonstrate normal or near-normal strength and normal muscle tone and bulk. The report of VA examination in February 2008 reveals that, while motor strength in the lower extremities was decreased, it was 4 out of 5 in the left knee with the right side normal at 5 out of 5. There was good muscle tone and bulk. A private evaluation by Dr. Perez-Cunanan in March 2007 revealed that muscle strength in the quadriceps, hamstrings, and gastrocnemius were 5 out of 5. A VA examination in March 2008 reveals that power and coordination were normal in all four extremities. There was no atrophy or fasciculations. Knee reflexes were normal. A VA examination in June 2010 reveals that, on inspection, there was no warmth, no synovial swelling, no effusion, no popliteal swelling, and compression testing was negative. There was tenderness in the right and left knee. Reflexes were 2+, muscle strength was 5 out of 5, and sensation was intact. An examination in September 2010 reveals that, on inspection of the Veteran's knees, there is no warmth, synovial swelling, effusion, popliteal swelling, or tenderness noted, bilaterally. Muscle strength was 5 out of 5, bilaterally. Sensation was normal to pinprick and light touch throughout the lower extremities. Reflexes were 2+ in the patellar and Achilles tendons, bilaterally. A VA examination in November 2012 reveals that motor strength was 5 out of 5 on each knee. Moreover, the Veteran's gait was described as normal by the January 2006 VA examiner and by the June 2010 examiner, who noted that the Veteran walks normally with no cane or brace. Private evaluations by Dr. Perez-Cunanan in June 2007, July 2007, August 2007, and September 2007 also revealed a normal gait. The Board understands that the Veteran's central concern is that his knees are painful and weak. The Veteran has particularly emphasized the effect of his knee pain. This is reflected in the clinical evaluations, as is his perception of weakness and fatigue, as well as giving way and buckling which has caused him to fall on several occasions. However, it is important for the Veteran to also understand that without symptoms such as these, there would be no basis for even the current 10 percent rating for arthritis of the right knee and no basis for maintenance of the current 20 percent rating for arthritis of the left knee. In this regard, it is important to note that the range of motion testing does not meet the requirements of the current 10 percent evaluation for the right knee, let alone any higher evaluation. Moreover, with the sole exception of the findings in February 2008, range of motion testing for the left knee does not meet the requirements even a 10 percent rating, let alone the current 20 percent rating or any higher rating. Thus, without consideration of the problems he has cited, pain, weakness, giving way, and buckling, the current evaluations could not be justified. A noncompensable disability under diagnostic codes such as 5260 and 5261 is a prerequisite for compensation under the second or third parts of Diagnostic Code 5003. Only when arthritic pain does not cause limitation of motion, or causes a limitation of motion that does not rise to a compensable level, will a 10 percent rating under Diagnostic Code 5003 be appropriate. This is pertinent to the right knee which is rated under Diagnostic Code 5010-5003. Moreover, the range of motion for the left knee has only warranted a 20 percent rating on 1 occasion. While a reduction in the rating for limited extension is not before the Board, it must be acknowledged that the current rating contemplates all factors which limit motion, including pain, weakness (buckling and giving way), fatigue, and incoordination. While the Veteran and his attorney have emphasized the severity of the Veteran's pain, VA law does not contemplate the assignment of a disability rating on the sole basis of pain. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. These normal working movements of the body are evaluated in the case of a knee disability through range of motion testing and strength testing. In sum, on the basis of limitation of flexion and extension, a preponderance of the evidence is against any higher or separate ratings for either knee under Diagnostic Codes 5003, 5010, 5260, 5261. The Board acknowledges the assertion of the Veteran's attorney in the notice of disagreement that, in light of the February 2008 findings, a 60 percent rating is warranted under Diagnostic Code 5256. The Board simply notes that Diagnostic Code 5256 applies to ankylosis, which is defined as the "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint." Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), quoting Stedman's Medical Dictionary 87 (25th ed. 1990). There is no suggestion in any of the clinical findings that there is a fixation or bony union of either knee and the demonstrated range of motion is probative evidence against any such finding. The cited diagnostic code is not applicable in this case. The Board has also considered whether a separate rating is warranted for either knee on the basis of recurrent subluxation or lateral instability, as asserted by the Veteran's attorney. However, in this case, there is significant evidence weighing against such symptomatology. In fact, clinical testing for lateral instability and subluxation has been uniformly negative. In June 2010, the VA examiner found no ligament/rotatory instability. Drawer testing and McMurray's signs were negative as to both knees. In September 2010, the examiner found no ligament instability or rotatory instability. In November 2012, although the Veteran complained that his knees feel unstable at times, tests for anterior instability (Lachman's), posterior instability (posterior drawer), and medial-lateral instability (valgus/varus pressure) were all normal. There was no history of subluxation or dislocation. The Board observes that the terms "unstable" and "instability" can have many meanings, including instability in the normal plane of motion of the joint (weakness, buckling, giving way). Ratings based on limitation of motion, including weakness, incoordination, fatigue, etc. reasonably contemplate this type of instability. "Lateral" instability is a specific type of instability that is demonstrated by clinical testing, such as varus, and valgus stress, and which is not contemplated in a rating based on limited motion. This is why separate ratings may be applied where this specific symptomatology is demonstrated. While giving way and buckling have been described by the Veteran, the criteria under Diagnostic Code 5257 are specific in referring to "lateral" instability, and not instability in the normal plane of motion, which is considered as weakness or a combination of pain and weakness. As there is clinical support for weakness, but no clinical support for lateral instability, the Board has considered the Veteran's reports of feeling unstable as equivalent to weakness or giving way, and not true lateral instability or subluxation. Accordingly, the evidence weighs against any separate compensable rating under Diagnostic Code 5257. The Board has considered other diagnostic codes as well. Diagnostic Code 5258 rates on the basis of dislocation of the semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. A 20 percent rating is the only rating available. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of the semilunar cartilage. In the notice of disagreement, the Veteran's attorney asserted that the evidence of buckling establishes entitlement to a 20 percent rating under Diagnostic Code 5258. The Board disagrees with this assertion. Aside from the fact that Diagnostic Code 5258 does not mention buckling, the descriptions of buckling in this case are not consistent with what is described under Diagnostic Code 5258. The Veteran has described a sensation where he can no longer support weight on the knee, i.e., give-way weakness. Diagnostic Code 5258 is specifically directed towards meniscal or cartilage injury. While there is a history of a tear of the left knee meniscus in this case, this was surgically corrected, at which time a 100 percent rating was assigned for convalescence. There are no reports of further dislocation or symptoms following removal of semilunar cartilage pertinent to this appeal. The Board has addressed the Veteran's assertions as to buckling in the discussion of limitation of motion and arthritis above. This is consistent with the finding of a VA physician in March 2008 that complaints of buckling were associated with arthritis. The Veteran reported to the November 2012 VA examiner that his left knee meniscectomy residuals include stiffness and joint locking. The Board acknowledges that locking is among the criteria for a rating under Diagnostic Code 5258. However, based on absence of any other complaints of locking on the Veteran's part, and on the lack of any clinical demonstration of locking, the Board finds that the criterion of "frequent" locking is not demonstrated. Moreover, as reported above, the evidence regarding joint effusion has been entirely negative. Diagnostic Code 5262 rates on the basis of malunion or nonunion of the fibula and tibia, conditions which are neither shown nor alleged in this case. Diagnostic Code 5263 rates on the basis of genu recurvatum, a condition which is neither shown nor alleged in this case. Accordingly, these codes are not appropriate. Regarding scar residuals from the Veteran's left knee surgery, the November 2012 VA examiner found that there were no painful or unstable scars. There is no assertion on the Veteran's part that a separation rating is warranted for his surgical scar or on what basis. The Board acknowledges the assertion of the Veteran's attorney in the notice of disagreement that the provisions for muscle injuries (38 C.F.R. §§ 4.55, 4.56) should be considered in evaluating the Veteran's knee disabilities. The Board simply notes that service connection is not in effect for a muscle injury. The grant of service connection encompasses joint disability, i.e., degenerative joint disease and arthritis, including left knee meniscal damage. There are no clinical findings supportive of a muscle injury associated with either knee disability. Indeed, as noted in detail above, findings for muscle strength are normal or near-normal. To summarize the Board's findings, a rating higher than 10 percent is not warranted for the right knee and a rating higher than 20 percent is not warranted for the left knee. The requested separate ratings for lateral instability, ankylosis, buckling, and muscle injury are also not warranted. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. V. Increased Ratings - Neck and Back The current appeal regarding the neck disability arises from a service connection claim received at the RO in June 2009. In a June 2011 rating decision, service connection was granted for "chronic cervical strain" with a 20 percent rating assigned pursuant to Diagnostic Code 5237, effective July 6, 2009. The current appeal regarding the back arises from a service connection claim received at the RO in June 2003. In the June 2011 rating decision, service connection was granted for "lumbar strain with lower extremity radiculopathy" with a 10 percent rating assigned pursuant to Diagnostic Code 5237, effective June 30, 2003. The applicable rating criteria for intervertebral disc syndrome/disease, 38 C.F.R. § 4.72, Diagnostic Code 5293, were amended effective September 23, 2002. See 67 Fed. Reg. 54,345 (Aug. 22, 2002). The remaining spinal regulations were amended effective September 26, 2003. See 68 Fed. Reg. 51,454 (Aug. 27, 2003). The Board will hereafter designate the regulations in effect prior to the respective changes as the pre-amended regulations and the subsequent regulations as the amended regulations. The timing of this regulatory change requires the Board to consider the back claim under the appropriate pre-amended and amended regulations, and then apply the more favorable version. The Board emphasizes that the amended regulations may not be applied prior to their effective date. See Kuzma v. Principi, 341 F.3d 1327 (2003); Karnas v. Derwinski, 1 Vet. App. 308 (1991). The Board also notes that, only the amended version of the schedule for rating intervertebral disc syndrome may be applied, as the effective date of the amendment (September 23, 2002) is prior to the date the claim was received. In other words, pre-amended Diagnostic Code 5293 may not be applied in this case; however, Diagnostic Codes 5292 and 5295 may be applied if they prove more favorable than the amended regulations. Regarding the neck, only the amended regulations are applicable, as the claim was received well after the effective date of the amendment. At the time of the June 2003 back claim, lumbosacral strain was rated under former Diagnostic Code 5295. A 40 percent rating was available for severe impairment with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. A 20 percent rating was available with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. A 10 percent rating was assigned with characteristic pain on motion. A 0 percent rating was assigned with slight subjective symptoms only. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2003). Under former Diagnostic Code 5292, limitation of motion of the lumbar spine was assigned a 40 percent rating where severe, a 20 percent rating where moderate, and a 10 percent rating where slight. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2003). Effective September 26, 2003, disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include lumbosacral strain (Diagnostic Code 5237). A 100 percent rating is available for unfavorable ankylosis of the entire spine. A 50 percent rating is available for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is available for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 30 percent rating is available where forward flexion of the cervical spine is limited to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent rating is available where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 10 percent rating is available where forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (2): (See also Plate V). Under the amended Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent rating requires incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. A 40 percent rating requires incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 20 percent rating requires incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 10 percent rating requires incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. The amended regulations provide that intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. Here, there is no intervertebral disc syndrome of the cervical spine (see the October 2012 VA examination report). Accordingly, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not applicable to the neck disability. Thus, regarding the back disability, in order to substantiate entitlement to a higher 20 percent rating under the amended regulations, the evidence would have to show that forward flexion of the thoracolumbar spine is not greater than 60 degrees or that the combined range of motion of the thoracolumbar spine is not greater than 120 degrees. A 20 percent rating can also be established under the amended regulations if there are muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. As the Veteran has been found to have lower extremity radicular symptoms, and as the grant of service connection specifically includes lower extremity radiculopathy, a higher rating can also be established if there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Under the pre-amended regulations, a higher rating for the back can be established if it is shown that there was moderate limitation of motion or that there was muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. As noted above, the pre-amended criteria for intervertebral disc syndrome cannot be applied based on the date of claim. Regarding the neck disability, as only the amended regulations are applicable, in order to substantiate a rating in excess of 20 percent, the evidence would have to show that forward flexion of the cervical spine is limited to 15 degrees or less, or that there is favorable ankylosis of the entire cervical spine. The report of VA examination in April 2004 reveals that range of motion of the back was normal in all planes. Forward flexion was measured by the examiner from 0 to 90 degrees; extension was from 0 to 30 degrees; lateral flexion was from 0 to 30 degrees; and rotation was from 0 to 30 degrees. There were no muscle spasms or swelling detected. The combined range of motion as calculated by the Board is 240. The report of a VA examination in January 2006 reveals neck forward flexion to 45 degrees, extension from 0 to 45 degrees, lateral flexion from 0 to 45 degrees, bilaterally, and lateral rotation from 0 to 80 degrees, bilaterally. There were no spasms. Lumbar forward flexion was to 90 degrees, extension to 30 degrees, lateral flexion to 30 degrees, bilaterally, and lateral rotation to 30 degrees, bilaterally. The combined range of motion as calculated by the Board is 240. Lordotic curvature was normal. There were no spasms. A private physician (Dr. Perez-Cunanan) measured range of motion from 8 degrees extension to 90 degrees forward flexion in March 2007. Range of motion of the neck was full. In May 2007, neck range of motion was also full. Active range of motion of the lumbar spine on April 12, 2007 was from 5 degrees extension, 25 degrees flexion, 8 degrees lateral flexion, bilaterally, and 12 degrees rotation, bilaterally. The combined range of motion calculated by the Board is 70 degrees. A private physician (Dr. Bash) examined the Veteran on June 16, 2009 and reported lumbar flexion to 40 degrees and extension to 5 degrees. Lateral flexion was to 15 degrees, bilaterally. Rotation was to 30 degrees bilaterally. The combined range of motion as calculated by the Board is 135. Cervical flexion was 5 degrees; extension was 20 degrees; lateral flexion was 15 degrees, bilaterally, and rotation was 30 degrees, bilaterally. The report of a November 2010 VA examination reveals that, during each of 3 trials of lumbar spine motion, forward flexion was measured to 70 degrees, extension was measured to 20 degrees, lateral flexion was measured to 20 degrees, bilaterally, and rotation was measured to 20 degrees, bilaterally. The combined range of motion as calculated by the Board is 350. Each excursion was accompanied by pain, fatigue, weakness, and lack of endurance. During each of 3 trials of cervical spine motion, forward flexion was measured to 30 degrees, extension was measured to 30 degrees, lateral flexion was measured to 30 degrees, bilaterally, and rotation was measured to 60 degrees, bilaterally. Each excursion was accompanied by pain, fatigue, weakness and lack of endurance. There were no muscle spasms. The report of VA examination in November 2012 reveals that, as measured with a goniometer, forward flexion of the thoracolumbar spine was to 80 degrees with onset of pain at 80 degrees; extension was to 25 degrees, with onset of pain at 25 degrees; lateral flexion was to 25 degrees, bilaterally, with onset of pain at 25 degrees; rotation was to 25 degrees, bilaterally, with onset of pain at 25 degrees. The combined range of motion as calculated by the Board is 205. After 3 repetitions, forward flexion was measured to 70 degrees; extension was measured to 15 degrees; and lateral flexion and rotation were each measured to 15 degrees. The combined range of motion as calculated by the Board is 145. The Veteran experienced limited motion, weakened motion, excess fatiguability, incoordination, and pain with motion. Guarding and/or muscle spasm was present (not specific as to which), but do not result in abnormal gait or spinal contour. The examiner noted that the Veteran complained of pain at 7 out of 10, which was constant. His back locks up at times. He has frequent back spasms. During flare ups he is unable to walk, stand, or sit for prolonged periods. He is unable to bend, stoop, squat, or lift more than 10 lbs without experiencing pain and spasms. Forward flexion of the cervical spine was measured to 20 degrees with onset of pain at 20 degrees. Extension was measured to 20 degrees with onset of pain at 20 degrees; lateral flexion was measured to 30 degrees with onset of pain at 30 degrees; rotation was measured to 30 degrees with onset of pain at 30 degrees. Measurements remained the same after 3 repetitions. In addition to decreased motion, there was weakened movement, excess fatiguability, incoordination, and pain on motion. Guarding or muscle spasm was present, but did not result in abnormal gait or spinal contour. Based on the measured range of motion findings for the thoracolumbar spine, the Board finds that a staged rating is appropriate. The first measurement that meets the criteria for a 20 percent rating is on April 12, 2007. The June 2009 findings of Dr. Bash also meet the criteria for a 20 percent rating. However, the November 2010 and later findings do not meet the criteria for a 20 percent rating. Accordingly a staged rating of 20 percent is warranted from April 12, 2007 to November 18, 2010. Effective November 18, 2010, a 10 percent rating is the highest rating warranted. The Board also finds that, during the staged rating period, a rating in excess of 20 percent is not warranted as the evidence clearly does not reflect favorable ankylosis of the entire thoracolumbar spine or that forward flexion of the thoracolumbar spine was 30 degrees or less. The evidence also does not show severe impairment with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint spaces, or some of the above with abnormal mobility on forced motion. There are no findings consistent with listing of the spine or loss of lateral motion, or abnormal mobility on forced motion. Regarding the characterization of the extent of limited motion, i.e., severe or moderate limitation of motion under the pre-amended regulations, as the normal findings for forward flexion of the thoracolumbar spine are 90 degrees, the findings of 40 degrees in June 2009 and 25 degrees in April 2007 are in the intermediate or moderate range. Moreover, as these readings are significantly out of line with the overall disability picture demonstrated throughout the period on appeal, which includes findings of normal or slight limitation of motion, the Board finds that severe limitation of motion is not an accurate characterization, even during this period. Supportive of this finding are notations during the June 2009 evaluation that the Veteran walked with a normal gait. This is probative evidence regarding the retention of significant functional ability reflecting a more moderate degree of impairment. With the exception of the period of the staged 20 percent rating, the Board finds that the criteria for a disability rating in excess of 10 percent for the back disability are not met. Regarding the amended regulations, the evidence would have to show that forward flexion of the thoracolumbar spine is not greater than 60 degrees or that the combined range of motion of the thoracolumbar spine is not greater than 120 degrees. Alternatively, the evidence would have to show that there are muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Here, with the exception of the period of staged rating, the measured forward flexion has consistently exceeded 60 degrees and combined range of motion has consistently exceeded 120 degrees. Moreover, to the extent spasms have been noted, they have specifically been found not to result in an abnormal gait, or abnormal spinal contour. Regarding the pre-amended regulations, the Board finds that, based on normal findings for forward flexion in April 2004 and January 2006 (90 degrees), a finding in November 2010 that is 78 percent of normal, and a finding in November 2012 that was initially 89 percent of normal, and which after 3 repetitions was 78 percent of normal, the Veteran's lumbar limitation of motion cannot be described as moderate, but is no more than slight. Also supportive of the Board's finding that a rating in excess of 10 percent is not warranted before or after the period of the staged 20 percent rating are contemporaneous clinical findings reflective of back impairment. Notably, the April 2004 VA examiner observed that the Veteran stood straight and walked about the office without any limping. He moved without signs of pain or discomfort. He got up on the examining table and came down in a fashion that an individual without any back pain would. The Veteran could reach his ankles with his fingertips with ease and without any discomfort. He performed all maneuvers without any pain or discomfort. He could stand up on his toes and on his heels without any discomfort. The November 2010 examiner noted that the Veteran's gait was normal. He was able to walk on heels and toes. He was able to squat. Thus, the examinations prior to and after the staged rating reflect not only significantly better range of motion findings, but specific observations of the Veteran's ability to perform activities that would be impacted by a limited range of lumbar motion. In sum, the Board finds that moderate limitation of motion was not demonstrated before or after the staged 20 percent rating. Regarding Diagnostic Code 5295, while there has been recent evidence of muscle spasms, there is no evidence of loss of lateral spine motion, unilateral, in the standing position. Each measurement of lateral spine motion has been bilaterally consistent, and the Veteran has been shown to retain substantial lateral spine motion in comparison to the normal figures. The Board has also considered the amended schedule for intervertebral disc syndrome. The report of VA examination in April 2004 reveals the Veteran's account that, in the prior 10-14 years, he had at least ten major episodes of recurrences of back pain, and that six of these episodes required him to see a doctor. The report of VA examination in June 2010 for the left knee includes the Veteran's account that he had 6-10 incapacitating episodes in the prior year; however, this appears to be a reference to numerous conditions evaluated in that report. The report specifies that, with regard to the back, the Veteran had 2 incapacitating episodes in the prior twelve months requiring treatment and bed rest. The flare-ups could last up to two days. The total length of incapacitating episodes would have been four days. The report of VA examination in November 2012 reveals the Veteran's report that he had about 3 episodes of incapacitating episode lasting about 4 days in the last year. He was seen by PCP and given Flexeril. The examiner found that there were incapacitating episodes over the past 12 months due to IVDS at least 1 week but less than 2 weeks. The Board emphasizes that the rating criteria require specific evidence of incapacitating episodes. In order to meet the criteria for an incapacitating episode, there must be "bed rest prescribed by a physician and treatment by a physician." See Note (1). While there is no specific evidence of bed rest prescribed by a physician in the Veteran's case, the Board accepts the finding of the November 2012 examiner as an endorsement that bed rest was necessary for 1 week, but less than 2 weeks, during the prior year. However, this does not meet the criteria for a 20 percent rating under the rating schedule. The other findings similarly do not suggest incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Based on the measured range of motion findings for the cervical spine, the Board finds that a staged 30 percent rating is warranted from June 16, 2009, the date of the report of Dr. Bash showing forward flexion to 5 degrees until November 18, 2010. The Board also finds that, as there is no evidence of unfavorable ankylosis of the entire cervical spine, a rating in excess of 30 percent is not warranted during this period. Prior to and after this period, the criteria for a disability rating in excess of 20 percent are not met at any time. As only the amended regulations are applicable regarding the neck disability, the evidence must show that forward flexion of the cervical spine was limited to 15 degrees or less, or that there is favorable ankylosis of the entire cervical spine. With the exception of the finding of Dr. Bash in June 2009, the evidence consistently shows that the criteria are not met. Moreover, as with the back, the clinical findings regarding functional impairment are inconsistent with the rather extreme June 2009 finding of forward flexion limited to only 5 degrees. Indeed, the March 2008 VA examiner noted that the Veteran performed his neck movements well. The November 2010 examiner noted that the Veteran's posture, head carriage, and shoulder levels appeared to be normal. In sum, the findings immediately before and after the June 2009 result are in sharp contrast to the report of 5 degrees forward flexion. As such, with the exception of the staged 30 percent rating from June 16, 2009 to November 18, 2010, a rating in excess of 20 percent for the Veteran's neck disability is not warranted. To the extent any higher level of compensation regarding the back or neck is sought, the preponderance of the evidence is against the claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Regarding associated neurological abnormalities, the Veteran specifically asserts that he has neurological impairment of the upper and lower extremities that is associated with his neck and back disabilities. These separately appealed claims are being remanded, as is the issue of entitlement to an initial rating in excess of 10 percent of the service-connected left foot neurologic impairment. Adjudication of these issues will be deferred pending further development as specified in the remand below. VI. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2013), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). Regarding major depressive disorder, the Board finds that all the Veteran's symptoms are either explicitly part of the schedular rating criteria under the general formula for rating mental disorders at 38 C.F.R. § 4.130, are analogous to the schedular rating criteria (see 38 C.F.R. §§ 4.20, 4.21), or are "like or similar to" the schedular rating criteria (see Mauerhan at 442-43). The schedular rating criteria, Diagnostic Code 9434, specifically provide for disability ratings based on a combination of history and clinical findings and their overall level of impairment on occupational and social function. The Veteran's symptoms of irritability, social withdrawal, depressed mood, anxiety, and chronic sleep impairment are specifically included in the rating schedule, and the assigned 30 percent disability rating specifically rates on the degree of occupational and social impairment, including due to specific symptomatology reported here. Moreover, the GAF scores indicated in the DSM-IV, which reflect overall degree of impairment due to psychiatric disorders, and which the Board weighed and considered in this case, are part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the Veteran's service-connected major depressive disorder, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Regarding the bilateral knee disabilities, the Board finds that the first Thun element is not satisfied here. The Veteran's service-connected knee disabilities are manifested by signs and symptoms such as pain, stiffness, swelling, weakness, fatigability, and lack of endurance, which impairs his ability to stand and walk for long periods. These signs and symptoms, and their resulting impairment, are entirely contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the knee and leg provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 2560 and 5261 (providing ratings on the basis of limited flexion and extension). For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in standing, walking, climbing, and stooping. In short, there is nothing exceptional or unusual about the Veteran's knee disabilities because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. Because the schedular rating criteria contemplate fully the Veteran's disability picture, application of the regular schedular standards is not rendered impractical. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Regarding the neck and back disabilities, the schedular criteria specifically provide for ratings based on the presence of arthritis, and limitation of motion of the neck and back, including due to pain, weakness, fatigue, incoordination, and incapacitating episodes. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. Such factors are explicitly part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). VII. Duties to Notify and Assist VA has obligations to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a) (2013). The Board's grant of service connection for asthma is a full grant of the benefit sought on appeal; discussion of VA's notice and assistance obligations is moot as to that issue. The effective date and disability rating appeals decided above arise from granted claims of service connection. The claimaint bears the burden of demonstrating prejudice fr om defective notice with respect to the "downstream elements" of the initial rating and effective date assigned. Goodwin v. Peake, 22 Vet. App. 128, 136-37 (2008). The Veteran, who is represented by an attorney, has not asserted that there was any deficiency in the notice provided by the RO. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's written assertions. The Board notes that the Veteran was asked by the September 2010 VA joints examiner whether he was receiving disability benefits from the Social Security Administration (SSA). He replied that he was not receiving SSA benefits because he had been advised that he did not have sufficient hours to qualify. There is no indication from the record that the Veteran actually applied for SSA benefits or that SSA would be in possession of any pertinent records. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of his service-connected psychiatric disability, knee disabilities, neck disability, and back disability. The Board finds that these examinations taken as a whole provide an adequate evidentiary basis to evaluate the claims. The Veteran's attorney has generally disputed the adequacy of musculoskeletal examinations, asserting in the notice of disagreement that the testing does not comply with 38 C.F.R. § 4.59. The Board finds that while there is some variation in the testing conducted, in this case there is a very detailed clinical picture for each of the service-connected disabilities spanning the entire period on appeal. Repeat range of motion findings were routinely reported, as were associated symptoms such as pain, fatigue, weakness, incoordination, etc. Moreover, the November 2012 examiner specifically noted that a goniometer was used in range of motion testing. Overall, the Board finds that the extensive clinical evidence in this case provides an adequate evidentiary basis to fairly adjudicate these claims, and further development is not necessary. ORDER An effective date earlier than April 4, 2005 for the grant of service connection for Tourette's syndrome is denied. An effective date earlier than July 22, 2011 for the grant of service connection for major depressive disorder is denied. Service connection for asthma is granted. A disability rating in excess of 30 percent for major depressive disorder is denied. A disability rating in excess of 10 percent for right knee degenerative arthritis is denied. Prior to February 13, 2007 and since May 1, 2007, a disability rating in excess of 20 percent for left knee degenerative joint disease is denied. From June 16, 2009 to November 18, 2010, a 30 percent disability rating, but not higher, for a neck disability is granted. Prior to June 16, 2009 and since November 18, 2010, a disability rating in excess of 20 percent for a neck disability is denied. From April 12, 2007 to November 18, 2010, a 20 percent disability rating, but not higher, for a back disability is granted. Prior to April 12, 2007 and since November 18, 2010, a disability rating in excess of 10 percent for a back disability is denied. REMAND There are two conflicting opinions regarding the etiology of the Veteran's upper and lower extremity neurologic impairment, neither of which is adequate to support a decision on the issues of entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, or entitlement to service connection for peripheral neuropathy of the right lower extremity. A medical opinion is necessary to resolve these issues. In a March 2008 opinion, a VA physician diagnosed idiopathic polyneuropathy of the upper and lower extremities. The examiner opined that this was not related to Tourette's syndrome, the service-connected knee conditions, or to the service-connected lumbar disc condition. Rather, it was suspected to be related to nutritional factors and recent weight loss of 30 pounds, and also small amount of alcohol intake. The Veteran's symptom of radiating pain from the lower back to the right leg was found to be related to lumbosacral osteoarthritis and perhaps degenerative disc disease, and was not related to the polyneuropathy. In a June 2009 opinion, Dr. Bash noted the findings of the March 2008 examination but concluded that the Veteran's peripheral neuropathy was due to unspecified "experiences/trauma" that the Veteran had during service. He continued that the Veteran was exposed to "several types of neurotoxins" while in service in the form of "cleaning solvents" and that neurotoxins are a known cause of peripheral neuropathy. The Board finds that the March 2008 VA opinion is inadequate because the portion of the opinion relating the diagnosis to nutritional factors and alcohol intake appears to be speculative. The terminology "suspected" does not convey sufficient certainty to be considered a conclusive opinion. Moreover, the rationale for the opinion is not provided. The June 2009 opinion is also inadequate to resolve these issues. While he acknowledged the March 2008 VA report, Dr. Bash did not acknowledge the opinion of that examiner at least suggesting a relationship between nutritional factors and alcohol intake. Dr. Bash also appears to have made the logical leap that the cleaning solvents used by the Veteran during service contained neurotoxins. There is no meaningful discussion of how this conclusion was reached and no acknowledgment that Dr. Bash actually knew the identify of the particular solvents involved. There was also no discussion of whether the onset of symptoms is consistent with an etiology of in-service chemical exposure. In short, Dr. Bash did not provide a thorough or cogent explanation of his reasoning. As there is yet no adequate opinion regarding the etiology of the diagnosed idiopathic peripheral neuropathy of the upper and lower extremities, the Board finds that a remand for a medical examination and opinion is necessary. Regarding the claim of entitlement to a compensable disability rating for dermatographism, the Board notes that the most recent VA examination to evaluate this claim was in January 2006, eight years ago. At that time, the Veteran complained of a rash on his back and torso and occasionally the upper legs. On examination, there were no obvious wheals or pruritic lesions; however, the examiner drew a 3-4 inch mark on the Veteran's back which became slightly pale and then red, lasting for several minutes. In the notice of disagreement received in July 2011, the Veteran's attorney reported that the Veteran's skin was so sensitive that the mere touch of a body part will irritate his skin; turn it red; then swell up with hive looking welts. These symptoms can last for days. Based on the description of the Veteran's attorney, it would appear that the condition has worsened since the most recent VA examination. Moreover, the manifestations of the disability are not well documented. The condition that was initially service connected - dermatographism, has been rated as a disorder of the arteries (angioneurotic edema). However, an April 2008 outpatient dermatology note reveals a diagnosis of allergic dermatitis. It is unclear whether these disorders are related. Further clarification of the symptoms associated with the service-connected disability is necessary. As the evidence obtained on remand is likely to be pertinent to the issue of entitlement to an initial disability rating in excess of 10 percent for left foot neurological impairment and entitlement to TDIU, those issues are also remanded. Accordingly, these issues are REMANDED for the following action: 1. Schedule an appropriate VA examination to determine the nature and etiology of the Veteran's upper and lower extremity neurological impairment. The relevant documents in the claims file should be made available to the VA examiner. The examiner is asked to review the claims file with particular attention to the June 16, 2009 report of Craig N. Bash, M.D., and the March 11, 2008 VA examination report. The examiner should make findings as to the manifestations and severity of the Veteran's upper and lower extremity neurological impairment. Please note that any neurologic abnormalities deemed to be associated with the service-connected neck or back disability are service connected. After rendering all appropriate diagnoses, the VA examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that any diagnosed neurological disorder of the upper and lower extremities is causally or etiologically related to the Veteran's service or is associated with his service-connected neck and back disabilities, i.e., radiculopathy. For purposes of this opinion, the examiner should accept as true the Veteran's report that he used and was exposed to various cleaning solvents and other chemicals used in operating, cleaning, welding, and maintaining boilers and heating systems. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. 2. Schedule an appropriate VA examination to determine the manifestations and severity of the Veteran's dermatographism. The relevant documents in the claims file should be made available to the VA examiner. The examiner should provide all current symptomatology that is associated with the service-connected dermatographism. The examiner should provide an opinion as whether the currently applied rating criteria (angioneurotic edema) are appropriate to the disability, or whether the disability would more appropriately be rated as urticaria, dermatitis, or some other skin condition. Please also provide findings pertinent to the rating criteria deemed appropriate, i.e., frequency and duration of episodes and percentage of bodily coverage and total area of coverage. 3. Readjudicate the remanded issues. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2013). These issues must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ____________________________________________ J.B. FREEMAN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs