Citation Nr: 1437293 Decision Date: 08/20/14 Archive Date: 08/27/14 DOCKET NO. 06-02 319 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to a rating in excess of 20 percent prior to May 1, 2014 and a rating in excess of 60 percent thereafter for low back pain, paravertebral myositis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active service from July 1991 to January 1995 and from October 2003 to July 2004. This appeal comes to the Board of Veterans Appeals (Board) from a January 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico, which, inter alia, increased the Veteran's disability rating for low back pain, paravertebral myositis, to 20 percent. This matter was remanded to the RO for additional development in December 2008 and June 2010. This development was completed and the appeal was returned to the Board. In a December 2011 decision, the Board denied the claim for a disability rating in excess of 20 percent for the low back disability. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In May 2013, the Court issued a Memorandum Decision vacating the Board's December 2011 decision and remanding the claim to the Board for further proceedings consistent with the Memorandum Decision. In December 2013 the Board remanded the claim for further development. It has since returned to the Board. FINDINGS OF FACT 1. Prior to May 1, 2013, the Veteran has had thoracolumbar flexion to at least 45 degrees, with only an occasional limitation to 30 degrees during episodes of flare-up pain, which occurred at most for one to two days every two to three weeks. 2. As of May 1, 2013, the Veteran has had incapacitating episodes due to IVDS of at least six weeks during a 12 month period but no unfavorable anyklosis of the entire spine. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent prior to May 1, 2013 for low back pain, paravertebral myositis have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5243 (2013). 2. The criteria for an evaluation of 60 percent, but no higher, for low back pain, paravertebral myositis have been met as of May 1, 2013. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5243 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When an evaluation of a disability is based on limitation of motion, the Board must also consider in conjunction with the otherwise applicable diagnostic code any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 CF R §§ 4.40 and 4.45. DeLuca v. Brown 8 Vet App 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C F R § 4.40 state that disability of the musculoskeletal system is primarily the inability due to damage or inflammation in parts of the system to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C F R § 4.40, Johnston v. Brown, 10 Vet App 80, 85 (1997). The Veteran is currently rated at 20 percent prior to May 1, 2014 and at 60 percent thereafter for low back pain, paravertebral myositis. Intervertebral disc syndrome (IVDS) can be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R.§ 4.25. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent evaluation is warranted when forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; when the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation requires either that forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or that favorable ankylosis of the entire thoracolumbar spine is shown. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, Note 2. Under the Formula for Rating IVDS Based on Incapacitating Episodes a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. A review of the evidence of record shows reports of a low back injury while lifting something heavy in June 2004 while on active duty. Private treatment records dated from 2003 to 2004 also reveal complaints of low back pain that radiated to the right leg for three months in September 2004 and November 2004. Examination of the back in November 2004 revealed decreased range of motion with 70 degrees in flexion and tenderness in the lumbosacral area. The assessment was low back pain with radiculopathy/back muscle strain. A November 2004 private magnetic resonance imaging (MRI) of the lumbar spine showed L4-L5 degenerative disc disease, circumferential disc bulge, posterior annular tear, and small disc herniation; mild spondylosis and degenerative endplate changes; and paraspinal muscle spasm suggested. VA treatment records dated in August 2004 and November 2004 also show complaints of low back pain. The November 2004 VA treatment record noted that the Veteran received an intramuscular (IM) shot three weeks prior due to his low back pain. At a December 2004 VA examination, the Veteran reported his low back pain was constant and ranged from moderate to severe in intensity. The Veteran reported that, in the last year, he went to his private doctor due to acute low back pain and was treated with Toradol injection, with good pain control for one day. He was seen at the VA medical center in August 2004 and November 2004 due to back pain, and was treated with medications. Precipitating factors for the low back pain included driving an automatic car, walking for 20 minutes, standing for 45 minutes, and sitting for one hour. Alleviating factors included medications, injections, and limiting activities. In the past year, he reported two episodes of acute low back pain that functionally impaired him. The pain lasted from one to two days. The Veteran walked unaided, but used a lumbosacral support at his job. There was no history of falls due to low back pain or history of surgeries to the lumbar spine. The Veteran was independent in his activities of daily living. He was limited at his job due to difficulty moving boxes and lifting more than 40 pounds. He was unable to run, play basketball, weight-lift, lift more than 40 pounds, or drive a standard-gear car. Inspection of the spine revealed a normal lumbar spine, lower limbs, posture, and gait. The lumbar spine had a range of motion of 0 to 50 degrees in flexion, 0 to 20 degrees in extension, 0 to 25 degrees in right and left lateral flexion, and 0 to 25 degrees in right and left lateral rotation. There was no painful motion. The Veteran was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. There was palpable lumbar spasm. There was tenderness to palpation in the lumbar area. VA treatment records show complaints of low back pain with radiation in April 2005 and December 2005. A March 2006 VA treatment record noted complaints of exacerbation of low back pain. A December 2006 VA treatment record also noted complaints of low back pain. April 2005, May 2005, October 2005, and January 2006 private treatment records noted complaints of low back pain with radiation. The back was tender to palpation with decreased range of motion of 60 degrees in flexion. Private treatment records also document reports of low back pain with stiffness, decreased range of motion, and radiation to the right leg in May 2007, October 2007, April 2008, and December 2008. The back showed a decreased range of motion of 60 degrees in flexion and less than 5 degrees in extension, tenderness to palpation in the lumbosacral area, and decreased deep tendon reflexes in the Achilles area. The Veteran additionally reported severe episodes of locking up. A January 2009 private treatment record noted complaints of recurrent and worsening low back pain with radiation to both buttocks and the right leg for the past six months. The pain ranged from a scale of 5/10 to 7/10. Examination showed decreased range of motion of 70 degrees in flexion; painful lateral movements, mostly on the right side; and tenderness to palpation. An MRI of the lumbar spine conducted on the same day indicated degenerative change of the lumbosacral spine, spondylosis, disc bulging, disc herniation, and disc protrusion with stenosis. A VA treatment record dated in November 2007 treatment record noted that the Veteran reported feeling better after receiving a shot from his private physician three weeks prior to the visit. In April 2008, the Veteran reported low back pain with radiation to the right leg. He complained of moderate low back pain episodes in January 2009 and occasional low back pain in February 2009. VA treatment records dated in June 2009, July 2009, also show complaints of low back pain and physical inactivity due to low back pain. A VA examination dated in February 2009 revealed complaints of worsening low back pain since the last VA examination, with radiation to the buttocks and right posterior leg, up to the calf, associated with numbness upon prolonged sitting or standing. The Veteran had difficulty lifting more than 20 to 25 pounds. He reported severe flare-ups every one to two months, with an intensity of 10/10 and duration of two to seven days. He reported symptoms of fatigue, decreased motion, stiffness, spasms, and pain. Inspection of the spine revealed normal posture, head position, and symmetry in appearance. There were no abnormal spinal curvatures, except for reverse lordosis. Examination showed evidence of spasm, pain with motion, and tenderness, but no atrophy, guarding, or weakness. The Veteran's lumbar spine had a range of motion of 0 to 65 degrees in flexion, 0 to 15 degrees in extension, 0 to 25 degrees in left and right lateral flexion, and 0 to 25 degrees in left and right lateral rotation. There was objective evidence of pain on active motion. There also was objective evidence of pain following repetitive motion, but there was no evidence of additional limitation of motion after three repetitions of range of motion. There was no ankylosis. Private treatment records dated from February 2009 to August 2009 showed additional complaints of worsening back pain. In February 2009 the Veteran reported strong lower back pain. Examination revealed decreased range of motion of 45 degrees or less. The following week after receiving an injection his flexion had increased to 45 to 60 degrees. He again reported strong lower back pain in March 2009. On examination his flexion was measured to 30 degrees or less. In May 2009 after reporting a flare-up of pain at a level of 7 to 9 out of 10 due to extended standing, testing showed flexion to 45 degrees or less. On examination in June 2009 he demonstrated flexion to 50 to 60 degrees. In July 2009 he reported a flare-up of pain to an 8 to 9 after a recent fall. Examination revealed flexion 30 degrees or less. On examination in August 2009 his flexion had returned to 60 degrees. Another VA examination was provided in July 2010. The VA examiner noted that the Veteran received additional treatment for back pain in 2010 and was recommended to undergo a neurosurgical examination by his private physician. He also received a lumbar epidural steroid injection in February 2010. The Veteran reported a pain level of 7/10 and indicated that he had limitations in straightening his back due to a burning sensation. He reported severe flare-ups every two to three weeks that lasted one to two days. He reported decreased motion; stiffness; spasm; and constant, burning pain that radiated into both legs. He used a brace as needed and was able to walk 1/4 of a mile. Inspection of the spine revealed that the pelvis was tilted to the left and an antalgic gait. There was lumbar flattening, but no cervical spine or thoracolumbar spine ankylosis. Examination revealed evidence of spasm, guarding, pain with motion, and tenderness, but no atrophy or weakness. Range of motion for the thoracolumbar spine was 0 to 55 degrees in flexion, 0 to 10 degrees in extension, 0 to 10 degrees in left lateral flexion, 0 to 12 degrees in right lateral flexion, 0 to 15 degrees in left lateral rotation, and 0 to 20 degrees in right lateral rotation. There was objective evidence of pain on active motion. There also was objective evidence of pain following repetitive motion. Further, there were additional limitations after three repetitions of range of motion due to pain. The range of motion after repetitive motion was 0 to 40 degrees in flexion, 0 to 5 degrees in extension, 0 to 8 degrees in left and right lateral flexion, 0 to 10 degrees in left lateral rotation, and 0 to 14 degrees in right lateral rotation. There was no evidence of weakened movement, excess fatigability, incoordination, swelling, deformity, or atrophy. Pain and tenderness were found upon palpation. A February 2010 MRI showed degenerative changes in the lower lumbar spine; and straightening of the lumbar lordosis, as may be seen with muscle spasm versus positioning. The examiner indicated that the range of motion documented in the progress notes with limited range of motion of less than 45 degrees were related to two acute exacerbations of pain and a period of prolonged standing. The VA examiner noted that the range of motion subsequently returned to 60 degrees following these acute episodes of pain. Subsequently, private treatment records indicate further treatment for back pain with radiation pain and stiffness in May 2010, June 2010, July 2010, August 2010, and November 2010, with range of motion testing showing flexion to 60, 50, 60, 45 and 45 to 60 degrees respectively. He further sought treatment in January 2011, February 2011, April 2011, June 2011, and August 2011. In both January and April the Veteran reported a flare-up of pain after extended standing a couple days prior. On examination both times his flexion was measured to 60 degrees. In February 2011 examination showed flexion to 45 degrees. In both June and August 2011 the Veteran's flexion was measured to 30 degrees or less. An August 2011 MRI of the lumbar spine showed central intervertebral disc herniation with annular tear at L4-L5 level, which was worse than on previous study. There also was a small central intervertebral disc protrusion at L5-S1 level and concentric intervertebral disc bulge at L3-L4 level. On May 1, 2014 the Veteran was afforded another VA examination. On that examination, the Veteran reported incapacitating episodes having a total duration of at least six weeks during the past twelve months. Therefore, the Board finds that the Veteran is entitled to a 60 percent rating effective May 1, 2013, which is 12 months prior to the date of the VA examination. A 60 percent rating is the highest available under the Formula for Rating IVDS Based on Incapacitating Episodes. Although a 100 percent rating is available under the General Rating Formula for Diseases and Injuries of the Spine, such a rating requires unfavorable anyklosis of the entire spine, which the Veteran does not have. Therefore, the Board finds he is not entitled to a rating in excess of 60 percent as of May 1, 2013. The Board further finds that the Veteran is not entitled to a rating in excess of 20 percent prior to May 1, 2013. The Board has considered both the Veteran's treatment records and VA examinations, as well as the Veteran's lay statements, in finding that even with consideration of the Veteran's reports of flare-ups, his condition did not more closely approximate the criteria for a rating in excess of 20 percent. The Board has specifically considered whether the Veteran's flare-ups of back pain are of such severity and frequency as to cause the Veteran's condition to more closely approximate the criteria for a rating in excess of 20 percent. In February 2009 the Veteran reported flare-ups ever one to two months for two to seven days. In July 2010 he reported flare-ups every two to three weeks for one to two days. The Board notes that for a 40 percent rating, there should be forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The evidence is clear the Veteran does not have ankylosis. Considerable range of motion testing is of record in this case from throughout the period on appeal. The vast majority indicate that the Veteran's flexion has been limited to no less than 45 to 60 degrees. However, the Board acknowledges a few measurements from the Veteran's private treatment records show flexion being limited to 30 degrees. The July 2010 VA examiner indicated that these findings were associated with acute episodes of back pain, which the Board finds is supported by the record. Private treatment records reflect that twice in 2009 and twice in 2011 the Veteran's forward flexion was measured to 30 degrees or less. Treatment records from 2009 indicate that the measurements were taken at a time the Veteran sought treatment due to a flare-up of pain. There are further additional treatment records from periods during which the Veteran reported flare-ups. For example, in May 2009 he reported having a flare-up of pain. His flexion was measured to 45 degrees at that time. In January and April 2011 he reported flare-ups after extended standing, and both times private treatment records show he was able to flex to 60 degrees. Thus, the evidence indicates that the Veteran has experienced additional functional loss during flare-ups shown by a reduction in his range of motion. However, even during a flare-up, the evidence shows that the Veteran's flexion only sometimes was additionally limited to 30 degrees or less. Therefore, in consideration of the frequency of the Veteran's reported flare-ups as well as their severity, the Board finds that the Veteran's condition overall does not more closely approximate the criteria for a 40 percent or higher rating. According to what the Veteran told the July 2010 VA examiner, his flare-ups, which are brought on by actions such as extended standing, encompass at most four days per month. Based on the evidence in the Veteran's treatment records from when he has sought treatment during a flare-up, when such episodes do cause additional functional limitation, not every episode even in and of itself meets the criteria for a rating of 40 percent or higher. Finally, considered as part of the Veteran's condition as a whole, the Board finds that overall his disability does not more closely approximate the criteria for a rating in excess of 20 percent. When not experiencing a flare-up, the Veteran has consistently been able to flex to between 45 and 60 degrees. Further, while the July 2010 VA examination found that there was additional limitation of motion after repetitive use, the range of motion after repetitive motion was still 0 to 40 degrees in flexion. While the Board acknowledges the Veteran's pain, the Board notes that the Veteran has nonetheless demonstrated notable range of motion despite that pain. While the Veteran may have some additional functional loss with flare-ups the Board finds that those additional limitations are not sufficient within the context of the Veteran's overall condition to warrant a rating in excess of 20 percent. Based on the forgoing, the Board finds that the overall evidence of record shows that the Veteran's lumbar spine has a range of motion of over 30 degrees in flexion in general and flare-ups are not of a frequency and severity such that the Veteran's condition as a whole can be considered to more closely approximate a higher rating. There also is no evidence of incapacitating episodes of at least four weeks, but less than six weeks, in duration, the criterion required for a 40-percent rating under Diagnostic Code 5243. During the February 2009 VA examination, the Veteran reported a maximum of one week and three days of prescribed bed rest. At the July 2010 VA examination, the Veteran reported being prescribed two days of bed rest in April 2010. Further, while he has submitted statements from employers attesting to the number of sick hours he has used for purposes of medical treatment, these statements do not specify whether bed rest was prescribed by a physician or whether sick leave was used to treat illnesses other than his lumbar spine disability. Therefore, the Board finds the Veteran is not entitled to a higher rating under the criteria for rating IVDS prior to May 1, 2013. The Board further notes that, while there are other diagnostic codes for spine disabilities that provide disability ratings in excess of 20 percent, they are not more appropriate because the facts of the case do not support their application. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Therefore, the Board finds a preponderance of the evidence is against a rating in excess of 20 percent prior to May 1, 2013. However, the Veteran is entitled to a rating of 60 percent effective May 1, 2013. The Board has also considered whether referral for consideration of an extraschedular rating is warranted. 38 C.F.R. § 3.321(b)(1). The determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that 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 adequate, and no referral is required. In this case, the medical evidence fails to show anything unique or unusual about the Veteran's service-connected low back pain, paravertebral myositis that would render the schedular criteria inadequate. The Veteran's symptoms, including pain and loss of range of motion are contemplated in the rating assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. Moreover, even if it were argued that the schedular rating criteria were inadequate, the Board finds no reason to refer the case to the Compensation and Pension Service to consider whether an extra-schedular rating is warranted. In this case, the evidence does not show hospitalization due to the Veteran's low back pain, paravertebral myositis or otherwise show an exceptional or unusual disability picture. In addition, the Board finds the record does not reflect that the Veteran's low back pain, paravertebral myositis markedly interferes with his ability to work, although the evidence does show he has missed some time from work due to the condition. However, the Board finds that that lost time is contemplated by the rating assigned. See 38 C.F.R. § 4.1 (indicating that generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). The manifestations of the Veteran's disability are considered by the schedular rating. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Duties to Notify and Assist Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of VCAA letters from the RO to the Veteran dated in September 2004 and January 2009. These letters effectively satisfied the notification requirements of the VCAA consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) by (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claim, (2) informing the Veteran about the information and evidence the VA would seek to provide, and (3) informing the Veteran about the information and evidence he was expected to provide. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Thus, the Board finds that the RO has provided all notice required by the VCAA as to the three elements of notice. 38 U.S.C.A. § 5103(a) . See Pelegrini II, Quartuccio, supra. With regard to the additional notice requirements for increased rating claims, as is the case here, the January 2009 VCAA letter also was compliant with the U.S. Court of Appeals for Veterans Claims' (Court) decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Specifically, this letter advised the Veteran of the evidentiary and legal criteria necessary to substantiate a higher rating for his back disability. In any event, the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) has vacated the Court's previous decision in Vasquez-Flores, concluding that generic notice in response to a claim for an increased rating is all that is required. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). Regardless, overall, the Board is satisfied that the RO provided both generic and specific VCAA notice as to the increased rating claim when considering all of the VCAA letters provided. With respect to the duty to assist, the RO has secured the Veteran's service treatment records (STRs), service personnel records (SPRs), and VA treatment records. Private treatment records also have been associated with the claims file. Further, the Veteran was provided VA examinations in connection with his claim. Finally, he also has submitted numerous statements in support of his claim. Thus, there is no indication that any additional evidence remains outstanding. The duty to assist has been met. 38 U.S.C.A. § 5103A. Finally, a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its December 2013 remand. ORDER A rating in excess of 20 percent prior to May 1, 2013 for low back pain, paravertebral myositis is denied. A rating of 60 percent for low back pain, paravertebral myositis is granted effective May 1, 2013. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs