Citation Nr: 1617430 Decision Date: 05/02/16 Archive Date: 05/13/16 DOCKET NO. 09-18 053 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a rating in excess of 10 percent prior to March 20, 2012, for a lumbar spine disability. 2. Entitlement to a rating in excess of 20 percent since March 20, 2012, for a lumbar spine disability. 3. Entitlement to a separate rating for neurological manifestations, including bowel impairment of the service-connected lumbar spine disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Mills, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1962 to June 1972. These matters come to the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, and an April 2008 rating decision by the RO in St. Petersburg, Florida. This matter was previously before the Board in May 2013, at which time it was remanded for further development. It is now returned to the Board. In a March 2012 Decision Review Officer decision, the Veteran's lumbar spine disability was increased to 20 percent, effective March 20, 2010. This increase during the appeal did not constitute a full grant of the benefit sought. Indeed, in August 2015, the RO continued the 20 percent rating for the lumbar spine disability. The records reflects that the Veteran continued to express disagreement with the rating, and requested a 40 percent rating in August 2015 correspondence. Therefore, the Veteran's claim for an increased evaluation for the lumbar spine disability remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board notes that the RO developed the issue of entitlement to an effective date earlier than March 20, 2012 for the award of a 20 percent rating for a lumbar spine disability as a matter for appeal. This "appeal" was initiated when the RO assigned a staged rating for the increased rating matter on appeal, and the Veteran desired that the higher staged rating be recognized from an earlier date. As the RO should have recognized, that is not properly an earlier effective date so much as is a staged rating issue. Given that the increased rating issue involving two separate periods is before the Board, that the Veteran does not allege that the lower 10 percent rating should have an earlier effective date, and that the Board has concluded that a 20 percent rating is only warranted as of March 20, 2012, the Board finds that there is no separate appeal concerning an earlier effective date. Instead, the Board will consider the Veteran's contentions in the context of determining whether the facts support a staged rating at other points during the appeal period. VA received additional evidence since the issuance of the most recent supplemental statement of the case. In March 2016, the Veteran, through his representative, submitted a waiver of initial RO review of this evidence. The issue of entitlement to a separate rating for neurological manifestations is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to March 20, 2012, the Veteran's lumbar spine disability was manifested by painful motion and flexion functionally limited to at most 80 degrees, but not by ankylosis, or intervertebral disc syndrome (IVDS). 2. For the period from March 20, 2012, the Veteran's lumbar spine disability was manifested by flexion functionally limited to at most 45 degrees, but not by ankylosis, or intervertebral disc syndrome (IVDS). CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent, for a lumbar spine disability prior to March 20, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.71a, Diagnostic Code 5243 (2014). 2. The criteria for a rating in excess of 20 percent, for a lumbar spine disability since March 20, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.71a, Diagnostic Code 5243 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.159 (2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from any notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). In this case, the record shows that the Veteran received 38 U.S.C.A. § 5103(a)-compliant notice in September 2004 and November 2007. The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran was provided VA examinations in August 2004, November 2007, August 2008, March 2012, and August 2015. The Veteran, through his representative, essentially argues that the March 2012 and August 2015 VA examinations are inadequate because the physician's assistant who conducted them is not licensed by the Alabama Board of Medical Examiners and Medical Licensure Commission. Such an assertion effectively challenges the competence of the examiner. The Board first points out that although the representative attempted to buttress his assertions by claiming several times that he himself worked in "medical provider credentialing" and thus had the special knowledge or skills to make his allegation, he provided no evidence corroborating his claimed experience. In any event, even assuming the truth of his allegation that the physician's assistant was not licensed to practice in Alabama, he has not established that the physician's assistant was unlicensed. The Board's own research shows that the physician's assistant is listed as being licensed, although the state of licensing is not identified, and the Board has no reason to doubt that the physician's assistant is licensed by a state. The Board also points out that, although the representative contends that the physician's assistant does not have an entry in the National Plan and Provider Enumeration System National Provider Identifier directory, he in fact is listed in that directory. To the extent the representative may believe that the physician's assistant must be licensed by Alabama in order to conduct VA examinations, the Board points out that the physician's assistant is employed by the Federal Government (and continues to be employed by the Federal Government, the understanding of the representative to the contrary notwithstanding). The representative has pointed to no law or regulation requiring a Federal Government employee who is performing his or her Federal duties at a Federal facility to be licensed only by the state in which that Federal facility is located. In short, the Board finds that it is enough that the physician's assistant is licensed, even if not by Alabama. The Board consequently finds that the physician's assistant is a medical professional. VA regulations provide that "[c]ompetent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions." 38 C.F.R. § 3.159(a)(1). "VA benefits from a presumption that it has properly chosen a person qualified to provide a medical opinion in a particular case." Parks v. Shinseki, 716 F.3d 581, 585 (Fed. Cir. 2013) (citing Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011)); Wise v. Shinseki, 26 Vet. App. 517, 524-27 (2014). It is presumed that VA follows a regular process that ordinarily results in the selection of a competent medical professional. Parks, 716 F.3d at 585 ("Viewed correctly, the presumption [of competence] is not about the person or a job title; it is about the process."). Thus, absent clear evidence sufficient to rebut the presumption of competence, the fact that a person was chosen by VA to provide an opinion generally assures that person's competence to provide the requested opinion. Sickels, 643 F.3d at 1366. Here, neither the Veteran nor his representative has submitted evidence to rebut the presumption of competence with respect to any VA examiner. The Board has considered the arguments of the representative as to the competence of the examiner, and finds them meritless. The Veteran has not referred to any additional, unobtained, relevant, available evidence. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Rating Disability ratings are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2015). The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Lumbar Spine The Veteran's lumbar spine disability is rated 10 percent disabling, effective December 2, 2003, and 20 percent disabling, effective March 20, 2012, under 38 C.F.R. § 4.71a, Diagnostic Code 5242. In a November 2004 rating decision, the RO acknowledged receipt of the Veteran's claim on July 30, 2004; however, the RO accepted the Veteran's claim as an expansion of a previous claim received December 2, 2003. As such, December 2, 2003, is the date of claim for the Veteran's increased rating claim. Then, in a March 2012 Decision Review Officer decision, the Veteran's lumbar spine disability was increased to 20 percent, effective March 20, 2010. Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a (2015). The General Rating Formula provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or a vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. The criteria of the General Rating Formula are applied with and 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. 38 C.F.R. § 4.71a (2015). Associated objective neurologic abnormalities are to be rated separately. The combined range of motion refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal range of motion of the thoracolumbar spine encompasses flexion to 90 degrees and extension, bilateral lateral flexion, and bilateral rotation to 30 degrees. 38 C.F.R. § 4.71a, Plate V (2015). The normal combined normal range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2015). Intervertebral disc syndrome is rated under the general formula for rating 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 rating when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2015). In rating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2015). Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45 (2015). The intent of the 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 (2015). When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). As noted on VA examination in August 2004, rating of motion testing was 15 to 80 degrees with objective evidence of pain on endpoint. Lateral bending was 20 degrees in each direction that was not painful. There was no straight leg raising pain and no positive sciatic tension signs. All muscle groups were intact and there was no atrophy noted. Reflexes in the knees were one-plus and symmetric. Ankle reflexes were absent bilaterally. The examiner noted the Veteran got on and off the examiner table without difficulty. The Veteran reported recurrent low back pain on a near daily basis since service. He denied true flare-ups but reported pain aggravated by strenuous activity such as yard work. He reported pain extending into the back of both legs down to the knee level. The examiner noted that the Veteran did not have true radicular pain below the knee and that there were no radicular sensory symptoms such as numbness or tingling anywhere. In a May 2007 Vat treatment, X-ray studies of the lumbar spine showed slight interval increase in multilevel degenerative changes. The examiner noted the disc space narrowing has slightly progressed. In a November 2007 VA examination, the Veteran reported daily back pain without flare-up. He indicated that the pain did not radiate below the knee, but that he did experience pain in the right lower extremity and diminished sensation or hip esthesia in the posterior aspect of the thigh. The examiner indicated that the Veteran did not experience pain that sounded like neurogenic claudication. The Veteran reported that he could walk up to four blocks at a time on some days and less when having pain. He reported that he could stand for 10 minutes and sit for 1 hour. He reported that his activities of daily living were considerably diminished when having severe pain and on his best days. The Veteran reported being retired since 1997 and light occasional part-time work. The examiner noted that the Veteran got in and out of his chair and on and off the examination table with minimal to moderate difficulty. It was noted the Veteran walked with a cane for support and had a mildly antalgic gait. Range of motion testing revealed flexion to 80 degrees, extension to 10 degrees, right and left lateral bending to 20 degrees, right and left rotation to 10 degrees. The examiner noted the Veteran heel and toe walked well. There was no straight leg raising pain. A minimal sciatic irritation sign on the left side was noted. Reflexes were symmetric at one-plus in the knees and absent bilaterally in the ankles. Motor and sensory function was entirely normal. There was no increased imitation of motion due to weakness, fatigability, or coordination. The examiner noted that repetitive use was not a problem during the examination. In an August 2008 VA treatment record, it noted the Veteran reported constant back pain made worse with constipation. He was issued a new back brace in August 2008. In an August 2008 VA examination, the Veteran reported nearly daily pain. He denied flare-ups of pain, but noted that pain was aggravated by strenuous activity such as yard work. The Veteran reported being able to carry out his activities of daily living with only minimal restriction with respect to strenuous activities. He reported fairly frequent pain extending into the back of both legs down to about the knee level. It was noted that the Veteran did not have true radicular pain below the knee and no radicular sensory symptoms such as numbness or tingling anywhere. He reported wearing a corset-type back support for many years. He could walk unaided and he did not require use of an assistive device. Physical examination revealed no paraspinous muscle spasms with a normal lumbar curvature. The Veteran could heel and toe walk well. Range of motion testing revealed extension to 10 degrees and flexion to 80 degrees with pain on endpoint. There was right and left lateral bending to 20 degrees without pain. There was no pain with straight leg raising and no positive sciatic tensions signs. All muscle groups were intact and there was no atrophy noted anywhere. Pin prick sensations were sharp in all areas. Reflexes in the knee were one-plus and symmetric. Ankle reflexes were absent bilaterally. The examiner noted the Veteran got on and off the examining table without difficulty. X-ray studies showed moderately advanced osteoarthritic changes of the lumbar spine and osteoarthritic of the lumbar spine. In a December 2008Va treatment record, after a review of spine films, it was noted there were no radicular symptoms and straight leg raises and deep tendon reflexes were normal. In a May 2009 statement, the Veteran noted complaints of pain radiating down to his left leg and constant back and buttock pain. He indicated that his sciatic pain made him jump out of his chair. He reported low back spasms that caused fatigue and that he compensated using his upper body to get in and out of chairs and the car. He reported use of a cane due to fatigue from constant pain. Following review of a July 2010 x-ray, a VA examiner noted slight worsening of degenerative changes with intervertebral disc spaces narrowed. In a July 2010 VA treatment note, the examiner found There are no fractures identified. The lumbar vertebral body heights were preserved. The impression was slight interval worsening of degenerative changes as described. In a November 2011 statement, the Veteran indicated that he was issued a cane and walker due to increased instability caused by his lumbar spine disability. He indicated that it was hard for him to stand or walk for long periods of time or distance. In a March 2012 VA examination, the Veteran complained of increased pain and that he chronically used a cane and wore a corset brace while ambulating during the day. The Veteran denied any flare-up. Range of motion testing revealed flexion to 45 degrees with pain, extension to 0 degrees with pain, right and left lateral flexion to 5 degrees without pain, and right and left lateral rotation without pain. The Veteran was unable to perform repetitive motion testing on forward motion. The examiner noted the Veteran could perform other range of motion two times each. It was noted the Veteran stood with pronounced stoop, which contributed to rotation, bending, flexion decreases recorded, and cancelled any ability to extend. The examiner noted pain on movement with repetitive motion testing. There was tenderness to palpation of the para-spinals and over the spinous processes of the lumbar area. The examiner noted abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. Muscle strength testing showed active movement against some resistance, a 4/5 measurement, for hip flexion and knee extension, and normal strength for the ankle plantar flexion, ankle dorsiflexion, and great toe extension. Reflex examination was hypoactive for the knees and absent for the ankles. Sensory examination was normal for the upper anterior thigh and knee and decreased for the lower leg and ankle, feet, and toes. Straight leg raising testing was negative. The examiner noted the Veteran had no radicular pain or signs or symptoms due to radiculopathy. No other neurologic abnormalities were noted. There was no IVDS on examination. The Veteran reported constant use of brace and cane. The examiner stated that the Veteran's lumbar spine disability did not impact his ability to work. The examiner noted the Veteran's diagnosis was degenerative disc disease as noted and not degenerative arthrosis. In a May 2012 VA treatment record, the examiner noted review of systems showed paraspinal muscle spasms bilateral lumbar spine. Then, in May 2012, the Veteran reported relief from back pain after a bowel movement. In a June 2012 statement, the Veteran clarified that he was claiming entitlement to compensation for radiculopathy as part of his lumbar spine disability. In an August 2012 VA treatment record, it was noted the Veteran complained of back pain and that he ambulated with a cane. In an August 2015 VA examination, Veteran reported that pain prevented him from picking up anything from below waist height and that he does not stand to ambulate for prolonged periods due to increased pain. Range of motion testing showed flexion to 50 degrees, extension from 0 to 10 degrees, and right and left lateral flexion to 15 degrees, and right and left lateral rotation to 5 degrees all with evidence of pain. The examiner noted that the Veteran's abnormal range of function did not contribute to a functional loss. It was noted that pain on examination did not result in or cause functional loss. The Veteran complained of tenderness to palpation from mid scapular are to sacrum. The examiner noted the Veteran displayed severe guarding and poor effort after two attempts of repetitive motion testing. It was noted the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner noted there was not enough objective information to assess whether pain, weakness, fatigability or incoordination significantly limited the Veteran's functional ability with repeated use over a period of time. The examiner noted localized tenderness not resulting in abnormal gait or abnormal spinal contour. The examiner noted guarding resulting in abnormal gait or abnormal spinal contour. The examiner noted less movement than normal due to ankylosis, adhesions, disturbance of locomotion, and interference with standing as additional factors contributing to the disability. Straight leg testing was negative. There were no signs or symptoms due to radiculopathy. The examiner noted there were no other neurologic abnormalities or findings related to the lumbar spine disability. There was no ankylosis of the spine. On sensory examination, response to light touch testing was absent. However, the examiner noted the Veteran either did not cooperate or did not understand the instructions because he responded to pinprick with essentially normal findings. The Veteran reported constant use of a brace and cane. The examiner found that the Veteran's lumbar spine disability had no impact on his ability to work. Prior to March 20, 2012 The Board finds that the Veteran is not entitled to a rating in excess of 10 percent for a lumbar spine disability prior to March 20, 2012. To warrant a 20 percent rating, there must be evidence of limitation of flexion greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a (2015). The Veteran's examinations show painful range of motion, with a limitation of flexion at 80 degrees on examination in August 2004, November 2007, and August 2008, thus warranting a 10 percent rating under 38 C.F.R. § 4.59, 4.71a. Rather, the examinations disclosed that he retained useful flexion that was better than 60 degrees. Additionally, there was no evidence of guarding or localized tenderness severe enough to be responsible for an abnormal gait or abnormal spinal contour. The Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent for a lumbar spine disability. The Board reaches that conclusion even when considering functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Although there was evidence of pain on endpoint of range of motion, such pain did not functionally limit flexion to less than 60 degrees. Here, neither the lay nor medical evidence establishes that flexion is functionally less than 60 degrees. Moreover, the Board has taken into consideration the Veteran's complaints of pain, fatigability, and use of assistive devices. In light of the fact that the Veteran is being rated for limitation of motion of the lumbar spine under Diagnostic Code 5242, any such pain and its effects on the Veteran's range of motion is contemplated in the rating currently assigned for this period of the appeal. Thus, the General Rating Formula and schedular criteria of Diagnostic Code 5242 cannot serve as a basis for an increased rating. Here, the 10 percent rating adequately compensates the Veteran for any pain, tenderness, weakness, fatigability, and incoordination associated with his service-connected lumbar spine disability, and none of the findings have been shown to be so disabling as to, effectively, result in a higher rating for limitation of motion. 38 C.F.R. § 4.71a (2015). The Board has examined the entire period involved in this appeal prior to March 20, 2012. Despite the Veteran's belief that his disorder met the criteria for a 20 percent prior to March 20, 2012, the Board finds that the evidence clearly shows that for the entire period, his lower back disorder did not approximate the criteria for a rating higher than 10 percent. Accordingly, for the period prior to March 20, 2012, the preponderance of the evidence is against entitlement to a rating in excess of 10 percent for a lumbar spine disability. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). March 20, 2012 to Present The Board finds that the Veteran is not entitled to a rating in excess of 20 percent for a lumbar spine disability after March 20, 2012. To warrant a 40 percent rating, there must be evidence of limitation of flexion to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a (2015). The Veteran's examinations show painful range of motion, with a limitation of flexion at 45 degrees on examination in March 2012 and at 50 degrees on examination in August 2015, thus warranting a 20 percent rating under 38 C.F.R. § 4.59, 4.71a. Here, the examinations disclosed that he retained useful flexion that was better than 30 degrees. Additionally, there was no evidence of favorable ankylosis of the entire thoracolumbar spine. The Board finds that the preponderance of the evidence is against the assignment of a rating higher than 20 percent for a lumbar spine disability. The Board reaches that conclusion even when considering functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Although there was evidence of pain on range of motion, such pain did not functionally limit flexion to less than 30 degrees. Here, neither the lay nor medical evidence establishes that flexion is functionally less than 30 degrees. Moreover, the Board has taken into consideration the Veteran's complaints of pain, use of assistive devices, and his range of motion after repetitive use testing. Indeed, the Board notes that the Veteran was unable to perform repetitive motion testing on forward motion on examination in March 2012 and that he displayed severe guarding and poor effort after two attempts of repetitive motion testing on examination in August 2015. In light of the Veteran's voluntary guarding and limited effort on examination, the Board has found that his orthopedic manifestations would not warranting a rating in excess of 20 percent under the general rating formula. The Board finds that any pain and limitation of motion are adequately contemplated in the rating currently assigned for this period of the appeal. Thus, the General Rating Formula and schedular criteria of Diagnostic Code 5242 cannot serve as a basis for an increased rating. Here, the 20 percent rating adequately compensates the Veteran for any pain, weakness, fatigability, and incoordination associated with his service-connected lumbar spine disability, and none of the findings have been shown to be so disabling as to, effectively, result in a higher rating for limitation of motion. 38 C.F.R. § 4.71a (2015). Accordingly, for the period since March 20, 2012, the preponderance of the evidence is against entitlement to a rating in excess of 20 percent for a lumbar spine disability. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Extraschedular The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for consideration of the assignment of an extra-schedular rating. 38 C.F.R. § 3.321(b)(1) (2015). In this case, the rating criteria for the musculoskeletal system reasonably describe the Veteran's disability level and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. The evidence does not show anything unusual or exceptional that would make the schedular criteria inadequate in this case. Here, the record shows that the Veteran's lumbar spine disability symptoms of pain, and limitation of motion are contemplated by the schedular criteria measurements specifically identified in Diagnostic Code 5242. His range of motion measurements are specifically contemplated by the schedular criteria as well. There is no indication that the average industrial impairment from the lumbar spine disability is in excess of that contemplated by the assigned rating. A higher rating is available for more severe levels of impairment, but the Veteran does not meet the criteria for the higher rating based on demonstrated range of motion. There is no lay or medical evidence to show frequent hospitalizations or that any disability caused marked interference with employment. There is also no evidence indicating any additional functional impairment caused by the collective impact of the Veteran's service-connected disabilities, nor has the Veteran alleged any such further impairment. See Yancy v. McDonald, No. 14-3390, 2016 WL 747304, at 10 (Feb. 26, 2016) (Referral for consideration of extraschedular evaluation for disabilities on a collective basis is only necessary when it is reasonably raised by the record); Johnson v. McDonald, 762 F.3d 1362 (2014). Based on the above, the Board finds that referral for extra-schedular consideration is not warranted. ORDER Entitlement to a rating in excess of 10 percent prior to March 20, 2012, for a lumbar spine disability is denied. Entitlement to a rating in excess of 20 percent since March 20, 2012, for a lumbar spine disability is denied. REMAND The Board finds that additional development is required before the remaining claim on appeal is decided. The General Rating Formula for Diseases or Injuries of the Spine allows associated objective neurologic abnormities, including bowel or bladder impairment, to be assigned separate evaluations, 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2015). In this case, the current medical evidence of record is inadequate to determine whether the Veteran's reported constipation and bowel impairment are the result of his service-connected lumbar spine disability. Although the Veteran did not report problems with constipation or bowels on VA examination, his VA treatment reports note such complaints. For example, an August 2009 VA treatment record notes the Veteran reported constant back pain made worse with constipation and a May 2012 VA treatment record notes the Veteran reported relief from back pain after a bowel movement. Although no VA examiners have found evidence of neurologic abnormalities on examination, their discussion only addresses the Veteran's complaints of radiating pain with no mention of his complaints of bowel impairment and constipation. The Board finds a remand is necessary to determine whether the Veteran is entitled to a separate rating for bowel impairment (constipation). VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Finally, the AOJ should identify any outstanding relevant VA and non-VA treatment records that are not currently associated with the claims file. 38 U.S.C.A. § 5103A (West 2014); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Associate any outstanding VA and non-VA treatment records that are not already associated with the claims file. 2. Refer the claims folder to the August 2015 VA examiner, if he is unavailable, to another appropriate examiner for a medical opinion to address the etiology of any associated neurologic abnormalities, to specifically included the Veteran's reported bowel impairment/ constipation. The examiner must review the claims file and must note that review in the report. Any further indicated tests and studies to an in-person examination should be conducted to identify all current neurological abnormalities associated with the lumbar spine disability. A complete rationale should be given for all opinions and conclusions expressed. The examiner should provide an opinion, as to the following: (a) Identify any manifested neurologic disability present during the period on appeal. Attention is invited to the August 2009 and May 2012 VA treatment records noting the Veteran's complaints of bowel impairment/ constipation. (b) Is at least as likely as not (50 percent or greater probability) that any identified neurologic abnormalities present during the period on appeal, are due to or caused by the Veteran's lumbar spine disability? (c) Is it at least as likely as not (50 percent or greater probability) that any identified neurologic abnormalities present during the period on appeal have been aggravated (permanently worsened beyond the natural progress of the disability) by the Veteran's lumbar spine disability? 3. Then, readjudicate the claim. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. ____________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs