Citation Nr: 1528467 Decision Date: 07/02/15 Archive Date: 07/15/15 DOCKET NO. 08-04 774 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for diabetes mellitus. 2. Entitlement to an effective date earlier than September 16, 2008, for service connection for residuals of a stroke. 3. Entitlement to an effective date earlier than November 1, 1999, for an increased rating of 30 percent for asthma. 4. Entitlement to an increased rating for a chronic adjustment disorder, currently rated as 30 percent disabling. 5. Entitlement to an increased rating for hypertension, currently rated as 10 percent disabling. 6. Entitlement to an increased rating for a lumbar spine disability, currently rated as 10 percent disabling. 7. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and observers ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from June 1973 to July 1975 and from December 1979 to October 1992. In April 2015, the Veteran testified before the Board at a hearing at the VA Central Office. This matter comes to the Board of Veterans' Appeals (Board) on appeal from May 2006, September 2007, and November 2009 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for diabetes mellitus and for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The June 2002 rating decision that denied service connection for a stroke is final. 2. The next formal or informal claim received for service connection for the residuals of a stroke was dated September 16, 2008. 3. The Veteran filed a claim for increased rating for asthma on December 15, 2004, and has been in receipt of the increased 30 percent rating throughout the appeal period to include one year prior to filing his claim. 4. Throughout the pendency of the appeal, the Veteran's chronic adjustment disorder has been productive of no more than occupational and social impairment with occasional decrease in work efficiency with intermittent inability to perform occupational tasks with depression, anxiety, and mild memory loss, but with otherwise satisfactory functioning, to include routine behavior, self-care, and normal conversation. 5. Throughout the pendency of the appeal, the Veteran's hypertension has not been manifested by blood pressure readings of diastolic pressure that were predominantly 110 or more, or by systolic pressure readings that were predominantly 200 or more. 6. Throughtout the pendency of the appeal, the Veteran's lumbar spine disability has been manifested by forward flexion greater than 60 degrees, with a combined range of motion of greater than 120 degrees, without evidence of muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. It was not been productive of incapacitating episodes or any associated neurological manifestations. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to September 16, 2008, for the grant of service connection for the residuals of a stroke have not been met. 38 U.S.C.A. § 5110(a), 38 C.F.R. §§ 3.156, 3.400 (2014). 2. The criteria for an earlier effective date for the assigned 30 percent rating for asthma have not been met. 38 U.S.C.A. § 5110(a), 38 C.F.R. §§ 3.156, 3.400 (2014). 3. The criteria for a rating in excess of 30 percent for a chronic adjustment disorder have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.125-4.130, Diagnostic Code 9440 (2014). 4. The criteria for a rating in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.124a, Diagnostic Code 7101 (2014). 5. The criteria for a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.71a, Diagnostic Code 5237 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The duty to notify in connection with the claims for increased ratings for hypertension and an adjustment disorder was satisfied in September 2005, and those claims were adjudicated in May 2006. The duty to notify in connection with the claim for an earlier effective date for the grant of service connection for the residuals of a stroke was satisfied in November 2009, and that cliam was adjudicated in November 2009. With regard to the claim for an earlier effective date for the assignment of a 30 percent rating for asthma, the Veteran received notice of the laws and regulations applicable to the assignment of an effective date in the September 2007 statement of the case that adjudicated the claim in the first instance, and the claim has since been adjudicated in a supplemental statement of the case. Although notice was not sent specifically as to the claim for increased rating for a low back disability prior to the May 2006 rating decision, the Board finds no prejudice to the Veteran in this instance, as notice with regard to the necessary elements to obtain an increased rating for that claim was provided in the December 2007 statement of the case. The claims were all subsequently adjudicated in the May 2014 supplemental statement of the case. Mayfield, 444 F.3d at 1333. With regard to the duty to assist, the VA has obtained the Veteran's service treatment records, as well as all identified VA treatment records and private records. The VA obtained the Veteran's Social Security Administration records in 1993, and there is no indication that more recent records exist, as the Veteran has not identified more recent records from that federal agency. The Veteran has not identified any additional, outstanding records necessary to decide his pending appeal. Additionally, the Veteran was afforded VA examinations in February 2006, May 2007, and January 2014 with regard to his claims for increased ratings. Those examinations addressed the severity of the Veteran's current psychiatric disorder, lumbar spine disability, and hypertension. The Board finds that from these examinations, clear conclusions with reasoned medical explanations were reached and are sufficient to decide the Veteran's claims. The Veteran was also provided with a hearing related to his present claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the VLJ explained the issues on appeal, and made note of the specific elements necessary to substantiate the claims. The VLJ also suggested the submission of any additional evidence. Accordingly, the Veteran is not shown to be prejudiced on this basis. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Earlier Effective Date Except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency, and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110(a); 38 C.F.R. §§ 3.400, 3.400(b)(2). An exception to that rule applies, however, in increased rating claims, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110(b)(2) (West 2014); see also 38 C.F.R. § 3.400(o)(2) (2014); Harper v. Brown, 10 Vet. App. 125 (1997). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 U.S.C.A. § 101(30); 38 C.F.R. § 3.1(p). The date of receipt shall be the date on which a claim, information or evidence was received by VA. 38 U.S.C.A. § 101(30); 38 C.F.R. § 3.1(r). Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claims must identify the benefit sought. 38 C.F.R. § 3.155 (2014). Under 38 C.F.R. § 3.157, a report of examination or hospitalization will be accepted as an informal claim for benefits. However the provisions of 38 C.F.R. § 3.157(b)(1) state that such reports must relate to examination or treatment of a disability for which service-connection has previously been established or that the claim specifying the benefit sought is received within one year from the date of such examination, treatment, or hospital admission. 38 C.F.R. § 3.157(b)(1). Residuals of a Stroke The Veteran contends that because he suffered from a stroke while in service in 1992, his current ratings for the residuals of a stroke, assigned by January 2009 and April 2009 rating decisions and which include paralysis of the left upper extremity, paralysis of the left lower extremity, and left facial droop, as well as an initial 100 percent rating for the residuals of a stroke that ended in March 2009, should date back to his separation from service in October 1992. However, the claims file reflects that in June 2002, the RO denied the Veteran's initial claim for service connection for a stroke stemming from the 1992 in-service hospitalization. While the Veteran filed a notice of disagreement to that decision in July 2002, and a statement of the case was issued on the matter in December 2002, a timely Form 9, formal appeal, was never filed with respect to the 2002 rating decision. Thus, that decision is final. In that regard, the Veteran has not alleged that there is clear and unmistakable error in the June 2002 rating decision. The Board notes here the Veteran's contentions that he has suffered from three strokes in his life. The first in service, the second in March 2007, and the third in September 2008. While the Veteran's representative contended at his April 2015 hearing that the Veteran filed an informal claim for service connection for a stroke on May 7, 2007, and that his current ratings should be effective beginning on that date, the Board finds that such is not the case. The claims file reflects that on that date, the Veteran "called for status - please call, do we need anything else from him? He had a stroke last month and wants to make sure everything is settled." For one, the Board finds that such correspondence does not document an intent to file a claim for stroke. Rather, the Veteran was clearly requesting that his open claims, for other disabilities, be "settled." The telephone call therefore does not indicate an intent to file a claim for a stroke as regulated under 38 C.F.R. § 3.155 (2014). More significantly, however, the currently service-connected stroke and related residuals stem from a stroke that occurred after this correspondence, in September 2008. It was not until that third stroke that the Veteran suffered from the left-sided residuals for which he is currently in receipt of service connection, and such is confirmed by the VA medical records. In that regard, in October 2012, the Veteran stated that prior to the 2008 stroke, all of his systems, to include the paralysis on his left side, were "completely functional." Therefore the claim cannot stem from the telephone call made in 2007, as the third stroke had not yet occurred. Thus, the Board finds that the first informal or formal claim for the Veteran's service-connected stroke and residuals thereof is dated September 16, 2008, when the Veteran called the RO and stated that he wished to file a claim for service connection for paralysis of the left side, including the face, arm, and leg. Such stems from the stroke the suffered earlier that month, on September 7, 2008. In summary, while the Veteran may have previously filed for service connection for the residuals of a stroke, such claim was denied in 2002 and was not timely appealed, and it thus final. In 2007, the Veteran informed the RO that he had suffered from a stroke, but did not state any intent at the time to file a claim for service connection for a stroke. Finally, the currently service-connected residuals of a stroke stem from the September 2008 stroke, for which the Veteran filed a claim for service connection on September 16, 2008. Accordingly, as the first communication that the Veteran intended to file a claim for his September 2008 stroke was on September 16, 2008, the claim for an effective date for service connection for that claim must be denied. Asthma The Veteran contends that the 30 percent rating assigned for his service-connected asthma should date back to 1992, when he was originally granted service connection for that claim. The Board notes an irregular procedural history with regard to the Veteran's claim. In that regard, the Veteran was first awarded service connection for asthma in November 1993, rated as 10 percent disabling, effective November 1, 1992, the first day of the month following service separation. A claim for a rating in excess of 10 percent was denied in a September 1995 rating decision. The Veteran did not properly appeal those decisions and they are thus final. The Veteran has not claimed clear and unmistakable error in those decisions. The Veteran next filed a claim for increased rating for asthma in January 2006. In May 2006, the RO increased the Veteran's rating for asthma from 10 to 30 percent, effective December 15, 2004, the date the Veteran filed a claim for increased rating for hypertension and an adjustment disorder. Then, in September 2007, the RO determined that there had been clear and unmistakable error in the May 2006 rating decision with regard to the effective date assigned, and changed the effective date for the increased rating for asthma to February 1, 1999, based upon medical records showing that he used inhalational therapy for his asthma since that date. The RO also issued a statement of the case on the matter. In January 2008, the Veteran stated that he disagreed with the effective date assigned for the increased rating for asthma. He also filed a Form 9. The claim has since been certified to the Board. First, it is unclear why the September 2007 rating decision found clear and unmistakable error in the May 2006 rating decision and granted an effective date of February 1, 1999, for the assignment of a 30 percent rating for asthma. There was no outstanding claim for an increased rating for asthma prior to December 2004, at the earliest. Because the previous rating decisions, dated in 1992 and 1995, are final, and there was no outstanding claim for an increased rating for asthma prior to December 2004, the Board finds that it cannot grant an earlier effective date under the law. In that regard, the Veteran has been in receipt of the higher 30 percent rating throughout the entire appeal period, including one year prior to the filing of his December 2004 claim. Thus, there is no earlier date upon which the Board could grant an earlier effective date for an increased rating of 30 percent for asthma, and the claim must be denied. Increased Ratings Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2014). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2014). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Chronic Adjustment Disorder The Veteran's chronic adjustment disorder has been rated as 30 percent disabling under DC 9440. A 30 percent disability rating is assigned for a mental disorder when 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when the psychiatric condition produces 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); inability to establish and maintain effective relationships. A maximum 100 percent rating is assigned when there is total occupational or 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, DC 9440. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 , (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a GAF score, which is defined by DSM-IV as number between zero and 100 percent, that represents the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). A GAF score of 61 to 70 is defined as indicative of some 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. See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). In this case, the Board finds that an increased rating is not warranted for the Veteran's chronic adjustment disorder. In that regard, the February 2006 VA examination reflects the Veteran's report that he was compliant with his medication and had follow-up visits with his psychiatrist once per month. He was not receiving counseling. His main symptoms included racing thoughts. Mental status examination was within normal limits, in that he was appropriately groomed, his speech was normal, and his thoughts were coherent and logical. He felt like his thoughts were racing and jumbled. His jumbled thoughts were considered to be related to his last manic episode. His memory was normal and his concentration was intact. His insight and judgment were fair. He was diagnosed with bipolar disorder type 1 with psychosis, and adjustment disorder. A GAF of 64 was assigned. The examiner concluded that the Veteran's presentation and current symptoms were most likely a result of his bipolar disorder. Such symptoms included his mood instability, paranoia, hallucinations, and racing thoughts. His anxiety adjustment was noted to be mostly unchanged and not limiting. On May 2007 VA examination, the Veteran reported that he lived alone and was separated from his spouse. He was doing some part-time volunteer work with his church. He reported feeling anxiety and depression. He was oriented in all spheres. He was casually dressed and groomed. His mood was appropriate and friendly. His speech and thoughts were linear and clear. His attention and concentration were within normal limits. His sleep was interrupted due to physical disabilities. Psychiatric testing was within normal limits but for some memory loss. Testing also showed the presence of some mild residual cognitive deficits secondary to his history of a stroke. He appeared to suffer from mild to moderate depression. He was diagnosed with bipolar disorder, by history. A GAF of 60 was assigned. It was concluded that his affective disorder was relatively quiescent. The prognosis was guarded due to the concern that he could relapse at any time which could cause mental decompensation. On January 2014 VA examination, the Veteran reported that he lived alone. He had two adult children. He lived in a public housing apartment for the disabled. He enjoyed reading the bible and other books, and watching sports games. He had several close friends but felt it best to stay by himself. He reported that he had tried to work at a call center but felt it was too stressful. His daughter had helped him set up an on-line business selling janitorial supplies but it had not been successful. He denied having had any mental health treatment. He was compliant with his medication. He reported a depressed mood. He denied having panic attacks. His level of interest in things was low. He would go out to dinner with his friends once a month. He had broken sleep attributable to racing thoughts. He reported trouble with his memory, and some mild problems with his attention and concentration. Mental status examination showed that his hygiene was marginal to adequate. He was alert and oriented. His behavior was cooperative. His communication was good. His mood was mildly depressed. His thought process and content were notable for being somewhat preoccupied with trying to get the Army to give him a medical retirement. There were no signs of delusions or hallucinations. The examiner concluded that the Veteran met the full DSM-5 criteria for a diagnosis of bipolar disorder. It appeared that his past adjustment disorder had been based on anxiety, sleep disturbance, and a focus on multiple physical complaints. He did not report any significant anxiety, however. His sleep trouble was due to racing thoughts, which were bipolar symptoms. He remained focused on his physical functioning, but that alone did not meet the criteria for a DSM-5 or DSM-IV diagnosis of an adjustment disorder. It was determined that the Veteran's mental disability resulted in social and occupational impairment contemplated by the 30 percent rating. In this case, the medical evidence contains medical opinions that differentiate the Veteran's bipolar disorder, for which he is not in receipt of service connection, from his adjustment disorder. In 2007 and in 2014, it was determined that he suffered from a bipolar disorder, and his current psychiatric symptoms, to include racing thoughts and sleep disturbance, were related to that nonservice-connected disorder. In 2014, it was determined that he did not meet the criteria for a diagnosis of an adjustment disorder. In 2007, his adjustment disorder was considered to be relatively quiescent, or inactive. Thus, the Board finds that an increased rating for a chronic adjustment disorder is not warranted, as the Veteran has not endorsed an increase in such symptoms during the appeal period. While the Veteran has shown some impairment to his memory and cognitively, such has not been tied to his adjustment disorder, but has rather been determined to be a residual of a previous stroke. While he endorses symptoms of depressed mood, anxiety, suspiciousness, sleep impairment, and mild memory loss, such symptoms are fully accounted for by the 30 percent rating. Significantly, on 2014 VA examination, the examiner determined that the Veteran's social and occupational impairment meets the criteria of the 30 percent rating. There is no indication in the record that the Veteran's chronic adjustment disorder has been more severe at any time during the appeal period. His primary symptoms have been clearly distinguished by medical professionals to be related to a nonservice-connected bipolar disorder. Thus, a rating in excess of 30 percent for a chronic adjustment disorder, which has been described as mostly unchanged and not limiting, quiescent, and no longer a current diagnosis, must be denied. Hypertension The Veteran's hypertension is rated as 10 percent disabling under Diagnostic Code 7101, which pertains to hypertensive vascular disease (hypertension and isolated systolic hypertension). Diagnostic Code 7101 defines hypertension as diastolic blood pressure predominantly 90 or greater. Isolated systolic hypertension is defined as systolic blood pressure predominately 160 or greater with a diastolic blood pressure of less than 90. A 10 percent rating is warranted where diastolic pressure is predominantly 100 or more; systolic pressure is predominantly 160 or more; or where an individual has a history of diastolic pressure that is predominantly 100 or more which requires continuous medication for control. A 20 percent rating may be assigned with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. Diastolic pressure of 120 or more is rated as 40 percent disabling, and a maximum 60 percent rating is warranted for diastolic pressure of 130 or more. 38 C.F.R. § 4.104, DC 7101 (2014). Turning to the evidence of record, on February 2006 VA examination, the Veteran reported taking medication daily for his hypertension, with no symptoms attributable to his hypertension. His blood pressure was 136/92 standing, 138/90, seated, and 140/88 supine. VA treatment records reflect that in May 2006, February 2007, and April 2007, the Veteran's hypertension was controlled. On May 2007 VA examination, his blood pressure was 160/90 supine, 150/95 sitting, and 140/90 standing. VA treatment records reflect that in 2009, the Veteran's blood pressure was stable, for example 128/84. In August 2010, the Veteran's blood pressure was 138/80 and was considered to be stable. In April 2014, his hypertension was noted to be well-controlled. On January 2014 VA examination, the Veteran reported taking daily medication for his hypertension. His blood pressure was 160/77, 167/78, and 159/76. In this case, the evidence fails to indicate that during the period on appeal, the Veteran had diastolic blood pressure readings of predominantly 110 or more or systolic blood pressure readings of predominantly 200 or more which would warrant assignment of a 20 percent rating, despite the Veteran's contentions. Therefore, a 20 percent rating is not warranted and the claim must be denied. 38 C.F.R. § 4.104, DC 7101 (2014). Lumbar Spine Disability Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the spine is considered a major joint. 38 C.F.R. § 4.45. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each group of minor joints so affected. 38 C.F.R. § 4.71a, DCs 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a , DC 5003. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003, Note 1. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Veteran's lumbar spine disability has been rated 10 percent disabling under Diagnostic Codes 5237, which pertains to lumbar strain. 38 C.F.R. § 4.71a, DC 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait pattern or spine contour such as scoliosis, reverse lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the lumbar spine 30 degrees or less, or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, 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. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. In this case, the Board finds that a rating in excess of 10 percent for a lumbar spine disability is not warranted. While the Veteran states that he suffers from constant back pain that restricts his ability to walk or sit for longer periods of time, or lift heavy objects, the medical evidence does not demonstrate that his range of motion is limited to the degree set forth in the higher 20 percent rating. Specifically, on February 2006, May 2007, and January 2014 VA examinations, the Veteran was able to forward flex greater than 60 degrees, even on repetitive testing. His combined range of motion was greater than 120 degrees. There was no indication of muscle spasm or guarding severe enough to result in an abnormal gait pattern or spine contour such as scoliosis, reverse lordosis, or abnormal kyphosis. Moreover, he had not been prescribed bedrest by a physician. Neurologically, while the Veteran reported in 2006 that he suffered from pain that radiated to his lower extremities, no radicular findings were elicited on physical examination. Additionally, no radicular abnormalities have been noted in the VA treatment records. On 2014 VA examination, it was concluded that the Veteran did not suffer from any associated neurological manifestations secondary to his lumbar spine disability. Finally, the Board is required to consider the effect of pain and weakness when rating a service-connected disability on the basis of limitation of motion. 38 C.F.R. §§ 4.40, 4.44; DeLuca, 8 Vet. App. at 202. The Board finds that the effect of pain and weakness on the basis of limitation of motion has been considered because although VA examinations and treatment records have shown that the Veteran experiences pain on motion and flare-ups on activity, there is no evidence to suggest that the functional loss is the equivalent to flexion less than 60 degrees, or any other limitation that would meet the next highest rating. Evidence of pain is an important factor for consideration. However, "pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Although the Veteran suffers from pain on flexion, extension, lateral flexion, and rotation, on VA examination, he was not shown to be additionally limited in range of motion. Thus, the Board has considered the Veteran's complaints of pain, as well as all evidence of record related to limitation of motion, weakened motion, excess motion, incoordination, fatigability, and pain on motion, but finds that the criteria for the next highest rating has not been met on that basis. III. Other Considerations An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disabilities. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected hypertension, psychiatric disorder, and low back disability with the established criteria found in the rating schedule. The discussion above reflects that the symptoms of the Veteran's hypertension, psychiatric disorder, and low back disability as they are contemplated by the applicable rating criteria. There are higher ratings available under the diagnostic codes, but the Veteran's disabilities are not productive of the manifestations that would warrant the higher rating. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). The Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). ORDER An effective date earlier than September 16, 2008, for the residuals of a stroke is denied. An effective date earlier than February 1, 1999, for an increased 30 percent rating for asthma is denied. A rating in excess of 30 percent for a chronic adjustment disorder is denied. A rating in excess of 10 percent for hypertension is denied. A rating in excess of 10 percent for a lumbar spine disability is denied. REMAND Additional development is necessary prior to further disposition of the claims for service connection for diabetes mellitus and for a TDIU. With regard to the claim for service connection for diabetes mellitus, the Veteran contends that his diabetes was caused or aggravated by his service-connected disabilities. He contends that his diabetes was caused by his obesity, which began following the onset of his service-connected asthma and while in service. He also contends that medication that he takes for his service-connected psychiatric disorder, Abilify and Lithium, are known to raise blood sugar levels and therefore could have also caused or aggravated his diabetes mellitus. In that regard, service treatment records reflect that June 1973, the Veteran weighed 184 pounds. In June 1990, he reported recent weight gain due to inactivity. In May 1992, he weighed 260 pounds. A March 1993 VA examination showed that he weighed 260 pounds, and was noted to have a very athletic build, though he was somewhat overweight. A March 1995 vocational rehabilitation examination reflects the Veteran's reported that he had gained 50 pounds since service separation. An October 1995 VA examination reflects the Veteran's report that he can no longer exercise due to his asthma. He denied a history of diabetes. On February 1997 separation examination, he weighed 280 pounds. VA treatment records reflect that in December 2004, the Veteran had recently been diagnosed with diabetes. In January 2006, the Veteran had been started on Abilify. He did not want to start medication to control his diabetes. In May 2006, the Veteran had not yet started medication for his diabetes mellitus. He had stopped taking Lithium. Given the Veteran's medical history as summarized, the Board finds that a medical examination and opinion should be obtained with regard to the etiology of his diabetes mellitus. The Board finds that the Veteran's claim for a TDIU must also be remanded, as that issue cannot be adjudicated until the claim for service connection for diabetes has been decided. Accordingly, the claim for a TDIU is deferred. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the etiology of his diabetes mellitus. The examiner should review the claims file. The examiner should provide conclusions and rationale for all opinions reached. The examiner should address the following: a) Is it at least as likely as not (within the realm of 50 percent probability or greater) that the Veteran's diabetes mellitus was caused or aggravated by his service, to include obesity in service? b) Is it at least as likely as not (within the realm of 50 percent probability or greater) that the Veteran's diabetes mellitus was caused or aggravated (beyond the normal progression of the disease) by i) his service-connected asthma or ii) medications taken for his service-connected chronic adjustment disorder, to include Lithium and Abilify? 2. Then, readjudicate the claim for service connection for diabetes as well as for a TDIU. If the decisions remain adverse to the Veteran, issue a supplemental statement of the case. Allow the appropriate time for response, then return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 2014). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs