Citation Nr: 1618271 Decision Date: 05/06/16 Archive Date: 05/13/16 DOCKET NO. 13-00 205A ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a thoracic or lumbar spine disability. 2. Entitlement to service connection for a left shoulder disability, to include left upper extremity radiculopathy (claimed as left shoulder and/or arm pain). 3. Entitlement to service connection for carpal tunnel syndrome. 4. Entitlement to service connection for a bilateral wrist disability. 5. Entitlement to service connection for a bilateral hand disability. 6. Entitlement to service connection for a peptic ulcer (claimed as an ulcer condition). 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for an eating disorder. 9. Entitlement to service connection for malnutrition. 10. Entitlement to an initial rating in excess of 20 percent for cervical disc disease. 11. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the right upper extremity. 12. Entitlement to a total disability rating based on individual unemployability by reason of service-connected disabilities (TDIU). 13. Entitlement to special monthly compensation based on loss of use. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD N. Nelson, Associate Counsel INTRODUCTION The Veteran served on active duty from February to June 2006, and from May 2007 to October 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2010 and December 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Offices (RO). The May 2010 rating decision continued a 20 percent rating for cervical disc disease, continued a 10 percent rating for radiculopathy of the right upper extremity, and denied service connection for a low back condition. The December 2015 rating decision denied service connection for a left shoulder disability, carpal tunnel syndrome, a bilateral wrist disability, a bilateral hand disability, a peptic ulcer, hypertension, an eating disorder, malnutrition, and special monthly compensation based on loss of use. In October 2015, the Veteran testified in a Board hearing before the undersigned at the RO on the issues of service connection for a thoracic or lumbar spine disability, and increased ratings for cervical disc disease and radiculopathy of the right upper extremity, and the transcript is of record. The Board notes that the Veteran has also perfected issues of increased ratings for migraine headaches, status-post laparoscopic cholecystectomy (claimed as removal of gallbladder), and esophagitis with gastritis (claimed as an ulcer), and service connection for a right shoulder disability, a bowel disability, decreased libido, and an acquired psychiatric disorder including PTSD. The Veteran perfected these claims in March 2016 when the RO received a timely VA Form 9. The RO, however, has not yet certified these issues to the Board and it appears there is currently an outstanding request for a Board videoconference hearing. As such, the Board will not address these issues in this decision and they will be the subject of a subsequent Board decision, if otherwise in order. The issues of service connection for a left shoulder disability, carpal tunnel syndrome, a bilateral wrist disability, a bilateral hand disability, a peptic ulcer, hypertension, an eating disorder, malnutrition, and entitlement to TDIU and a special monthly compensation based on loss of use 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 Veteran has diagnoses including lumbago, thoracolumbar strain, disc desiccation at L4-L5, and degenerative changes at L5-S1, and the evidence is in relative equipoise on the issue of whether the diagnoses are etiologically related to service. 2. For the entire period of appeal, the cervical disc disability is manifested by forward flexion limited to no more than 25 degrees, with no evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. 3. For the entire period of appeal, the right upper extremity radiculopathy manifested by symptoms of pain, decreased sensation, and trouble grasping objects, more nearly approximating moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for a thoracic or lumbar spine disability are met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). 2. For the entire period of appeal, the criteria for the assignment of a rating in excess of 20 percent for the cervical disc disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5237, 5243 (2015). 3. For the entire period of appeal, the criteria for the assignment of a rating of 40 percent for the radiculopathy of the right upper extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.69, 4.124a, Diagnostic Code 8510 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information and any medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA notice letters must also include notice of a disability rating and an effective date for award of benefits if service connection is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the RO provided a notice letter to the Veteran in November 2009, prior to the adjudication of the claims for service connection for a thoracic or lumbar spine disability, cervical disc disease, and radiculopathy of the right upper extremity. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claims for service connection, what information and evidence must be provided by the Veteran, and what information and evidence would be obtained by VA. The Veteran was told to inform VA of any additional information or evidence that VA should have, and was told to submit evidence to the RO in support of his claims. The letter also provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The Veteran's claim for a higher initial rating for the service-connected cervical disc disease and radiculopathy of the right upper extremity are downstream issues, which were initiated by the notice of disagreement. The Court has held that, as in this case, once a notice of disagreement from a decision establishing service connection and assigning the rating and effective date has been filed, the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements..." Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Thus, there is no duty to provide additional notice with regard to these claims. The record establishes that the Veteran has been afforded a meaningful opportunity to participate in the adjudication of his claims. The Board notes that there has been no allegation from the Veteran that he has been prejudiced by any of notice defects. See Shinseki v. Sanders, 556 U.S. 396 (2009). Thus, there is no prejudice to the Veteran in the Board's considering the issues of service connection for a thoracic or lumbar spine disability, and increased ratings for cervical disc disease and radiculopathy of the right upper extremity on their merits. The Board finds that the duty to notify provisions have been fulfilled with regard to these claims, and any defective notice is nonprejudicial to the Veteran and is harmless. The Board further finds that all relevant evidence has been obtained with regard to these claims, and the duty to assist requirements have been satisfied. All available service treatment records (STRs) were obtained, and VA medical records and private medical records are associated with the claims file. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to this claim. The Veteran underwent VA examinations in December 2009, November 2013, and August 2015 to obtain medical evidence regarding the nature and severity of the cervical disc disease, radiculopathy of the right upper extremity, and thoracic or lumbar spine disability. The Board finds the VA examinations adequate for adjudication purposes. The examinations were performed by medical professionals based on review of the claims file, solicitation of history and symptomatology from the Veteran, and examination of the Veteran. The examination reports are accurate and fully descriptive. Opinion is provided as the nature, etiology, and severity of any diagnosed conditions. As such, the Board finds that the Veteran has been afforded adequate examination with regard to these claims. The Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion for the thoracic or lumbar spine disability, cervical disc disease, and radiculopathy of the right upper extremity has been met. See 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the duties to notify and assist the Veteran have been met with regard to the claims for service connection for a thoracic or lumbar spine disability, and increased ratings for cervical disc disease and radiculopathy of the right upper extremity, so no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of these claims. II. Service Connection Law and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be also granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310(a) (2013); Allen v. Brown, 7 Vet. App. 439 (1995). VA adjudicators are directed to assess both medical and lay evidence. The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises, and may also include statements from authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A layperson is not generally capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Service Connection for a Low Back Disability The evidence of record indicates that the Veteran has various current diagnoses, including lumbago, thoracolumbar strain, disc desiccation at L4-L5, and degenerative changes at L5-S1, and the evidence is in relative equipoise on the issue of whether the diagnoses are etiologically related to active service. STRs show that in a January 2006 service enlistment examination, the Veteran's spine was found to be clinically normal, and he denied having recurrent back pain or any back problem. In March 2006, the Veteran complained of having lower back pain, along with frequent urination and radiation of pain. In February 2008, the Veteran was involved in a car accident and reported having back (and neck) pain. He was diagnosed with a cervical/lumbar strain. In March 2008, he was diagnosed with lumbago; however, results of an MRI of the thoracic spine were normal. In May 2008, physical examination showed no abnormalities or facet tenderness, deformities, or spasms. In August 2008, the Veteran reported having neck and right arm pain that radiated to his lower back. In November 2008, the Veteran was noted as having lumbago and midback pain. In March 2009, the Veteran's chiropractor, Dr. L.S., submitted a certification of permanency, in which he indicate that the Veteran's February 2008 car accident caused permanent injuries, including upper, mid, and lower back injuries. Diagnoses included acute post-traumatic thoracic and lumbosacral sprain/strain, thoracic neuritis/radiculitis, and subluxation of the thoracic spine. In an April 2009 Medical Board Examination for his neck and right arm, the Veteran indicated that he had back pain. In August 2009, the Veteran reported having upper back pain due to the prior car accident. He began a physical therapy exercise plan and had acupuncture. Post-service treatment reports indicate that in December 2009, the Veteran had tenderness on palpation over the paraspinous muscles. The thoracolumbar spine had a normal appearance. The Veteran underwent a VA examination in December 2009. He reported that he had constant neck and upper back pain, which radiated to his right shoulder and down into the thoracic spine. Upon physical examination, range of motion measurements of the thoracolumbar spine included forward flexion to 110 degrees (with pain at 90 degrees), extension to 15 degrees (with pain at 10 degrees), right and left lateral flexion to 30 degrees (with pain at 20 degrees), and right and left lateral rotation to 30 degrees (with pain at 30 degrees). After three repetitions of movement, ranges of motion were not additionally limited by pain, fatigue, weakness, or lack of endurance. There was tenderness to palpation over the thoracic lumbar spine and paravertebral spasm. The examiner opined that although the Veteran had subjective complaints of pain, there was no evidence to support a diagnosis of a thoracolumbar spine. She noted that the Veteran had essentially full range of motion of the spine. Private treatment records indicate that in October 2010, myofascial hyperthermia was noted over both trapezius and rhomboids areas, which was suggestive of chronic inflammation. In January 2011, the Veteran reported having back pain since 2008. He was diagnosed with lumbago, and was referred to a pain specialist. In October 2012, at an assessment with private pain consultants, the Veteran reported having left-side low back pain, which flared four days prior with radiation into the lower extremities. In December 2012, he reported a sharp, stabbing pain to the right of the thoracic spine. In June 2013, the Veteran's pain doctor noted that that he continued to assess the Veteran has having low back pain with bilateral radiculopathy. The Veteran had another VA thoracolumbar spine examination in November 2013. He reported having occasional pain and tenderness in the back with prolonged walking and standing, with occasional radiation of pain into the right upper extremity. He stated that he did not have flare-ups. Range of motion measurements included forward flexion to 90 degrees or greater (with objective evidence of painful motion at 80 degrees), extension to 30 degrees (with pain at 25 degrees), right and left lateral flexion to 30 degrees or greater (with pain at 25 degrees), and right and left lateral rotation to 30 degrees or greater (with pain at 25 degrees). There was no additional limitation in ranges of motion after repetitive-use testing. There was also no localized tenderness, pain to palpation, or muscle spasms of the thoracolumbar spine. There was also no radicular pain or any other signs or symptoms due to radiculopathy. X-rays showed questionable minimal convex left scoliosis of the lumbar spine, possibly positional, and questionable minimal degenerative changes of the thoracic spine. The examiner indicated that the Veteran had a diagnosis of chronic mild residuals of a thoracolumbar sprain, diagnosed in 2008. In October 2014, the Veteran reported having intermittent low back pain, which he stated had bene problematic since a motor vehicle accident in 2008. An MRI of the lumbar spine showed isolated degenerative disc change at the L5-S1 level. A March 2015 MRI of the lumbar spine showed decreased disc herniation compared to the October 2014 MRI findings. There was no evidence of lumbar spine compression fracture. In August 2015, the Veteran's physician, Dr. C.S., submitted a statement indicating that he reviewed the Veteran's STRs and medical history, including the February 2008 car accident, and asserted that the Veteran had a diagnosis of lumbar paravertebral myositis and disc desiccation and narrowing at L4-L5. He also indicated that the Veteran had chronic pain, muscle control difficulty, and tingling, numbness, and weakness in the legs. Dr. C.S. indicated that in his professional opinion the low back pain stemmed from the accident in 2008. He concluded that "it is more likely than not that the physical traumas suffered during the Veteran's military servicer as noted in his record caused, contributed to and aggravated the totally disabling back condition." The Veteran testified in a Board hearing in October 2015. He asserted that he has had a lower back diagnosis since the accident in February 2008, including lumbago and/or disc desiccation at the L4-5, and that he had a back brace that helped support and posture. In February 2016, the Veteran was seen again by a pain management specialist for a lower backache. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. Specifically, the Board could seek further examination to definitively opine on both the nature and the etiology of the current back conditions. However, under the law, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). In this case, the Veteran's lay statements are credible because they have been generally consistent and are consistent with the circumstances of his service. The Veteran is competent to describe his observable symptom of having pain in his back. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran's statements are also underscored by the medical evidence dated in February 2008, when he was treated for injuries after the motor vehicle accident and diagnosed with a cervical/lumbar strain. He has also consistently reported having back pain since then, which adds to the credibility of the Veteran's reports. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Most significantly, his treating physician concluded the condition was likely caused by the accident during service. The Board has considered the December 2009 VA examiner's opinion. The opinion, however, is outweighed by the multiple private treatment reports since then that provide various back diagnoses, including a November 2013 VA examination report. The December 2009 examiner's opinion also noted only that the Veteran had essentially full range of motion of the spine, and did not provide further rationale for the lack of diagnosis. As such, the Board finds that there is at least "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," and the benefit of the doubt rule applies. Ashley, 6 Vet. App. at 59; 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Thus, in resolving all reasonable doubt in the Veteran's favor, the Board finds the onset of the back disability was during service and service connection for a thoracic or lumbar spine disability is warranted. III. Increased Ratings Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). It is essential that the examination on which ratings are based adequately portray the anatomical damage and functional loss with respect to all these elements. Id. 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 or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or particular 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. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. The Court instructed that in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011). Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The Court explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Diagnostic Code 5010 (traumatic arthritis) directs that arthritis be rated under Diagnostic Code 5003 (degenerative arthritis), which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104(a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Factual Background Treatment reports from the Veteran's period of active service indicate that in February 2009, the Veteran reported having right shoulder pain for the past nine months. An MRI showed a normal right shoulder and did not show an abnormality to explain the Veteran's symptoms. In April 2009, the Veteran's cervical spine range of motion measurements included active forward flexion to 16 degrees, extension to 16 degrees, left lateral flexion to 15 degrees, right lateral flexion to 13 degrees, left lateral rotation to 36 degrees, and right lateral rotation to 23 degrees. Passive range of motion measurements included active forward flexion to 19 degrees, extension to 18 degrees, left lateral flexion to 20 degrees, right lateral flexion to 15 degrees, left lateral rotation to 38 degrees, and right lateral rotation to 26 degrees. He also had localized tenderness and guarding. In May 2009, in a Medical Board Examination, the Veteran reported continuing cervical pain with radiation into the right arm since a car accident in February 2008. Treatment records indicate that he had previously had physical therapy, facet injections, and steroid injections. X-rays showed mild multilevel uncovertebral and degenerative disc changes, most pronounced at the C4-C5 and C5-C6 levels. He was found to have cervicalgia and cervical disc herniation with C5-C6 radiculopathy. In August 2009, the Veteran had a cervical epidural steroid injection. Post-service treatment records indicate that in December 2009, the Veteran was afforded a VA examination. He reported having severe neck and back pain, which radiated to his right shoulder and arm. He stated that he attended physical therapy three times per week and took Oxycodone. He also stated that he had flare-ups of pain 4-5 times per week. Upon physical examination, range of motion measurements of the cervical spine included forward flexion to 25 degrees (with pain at 10 degrees), extension to 10 degrees (with pain at 5 degrees), right and left lateral flexion to 20 degrees (with pain at 10 degrees), and right and left lateral rotation to 20 degrees (with pain at 20 degrees). After three repetitions of movement, ranges of motion were not additionally limited by pain, fatigue, weakness, or lack of endurance. There was tenderness to palpation over the cervical spine, but no paravertebral spasm. The examiner diagnosed cervical disc disease with decreased range of motion and pain, and radicular pain stemming from the cervical spine radiating into the right upper extremity. She noted that the upper extremity pain was radicular pain, and not peripheral neuropathy. In January 2010, the Veteran reported having neck pain that went down the right arm, paresthesia, and weakness. He had pain on elevation of the arm, motion weakness, and pain on flexion and extension of the cervical spine. In an initial evaluation for physical therapy, the Veteran's posture was noted to be of severe concern; he had a forward head poster, rounded shoulder, and entire spine rested in a C-curvature. In April and December 2010, the Veteran had a cervical epidural steroid injection. In October 2010, he reported having radiating pain in his right shoulder, and having tingling and numbness. He was found to have patchy inflammation noted around the right shoulder, suggestive of arthritis, which was most likely referred from the cervical spine. He also had myofascial hyperthermia over the base of the posterior neck, which suggested cervical spine and muscular dysfunction, which may relate to whiplash injury. Private treatment records indicate that in August 2011, the Veteran noted that he continued to have neck pain that radiated to the right parascapular region. He had tender trigger points and his cervical range of motion was mildly decreased due to tightness and pain. He was assessed as having cervical spondylosis and myofascial pain. He subsequently had two trigger point injections later that month. In February 2012, the Veteran reported that his neck pain had greatly improved after the trigger point injections, although he was still taking Oxycodone. In May 2012, the Veteran reported that his right-side neck pain had recurred, and in July 2012 he reported that the left side of the neck hurt as well. He subsequently had trigger point injections in November 2012. In September 2012, the Veteran's friend, M.S., submitted a statement indicating that the Veteran needed help with daily activities, like laundry and other tasks. She stated that when they went grocery shopping, she had to carry all the heavy items because he was too weak or in too much pain to carry the items. In addition, when the Veteran drove, he had difficulty turning his head to the extremes. The Veteran's mother, E.D., also submitted a statement indicating that he could not sit still for long or carry heavy items. She also stated that his right arm prevented him from being able to open containers, and that he was in pain every day. In March 2013, the Veteran reported in a pain consultation that he had been getting a lot of radicular pain shooting into the right upper extremity with numbness in the fingers. In July 2013, the Veteran reported continued neck pain with radiation into the right upper extremity. His neck was tender to palpation. The Veteran had another VA cervical spine examination in November 2013. He reported having mild occasional pain in the neck with occasional "shooting" radiation of pain to the right upper extremity. He denied having flare-ups of pain. Range of motion measurements showed forward flexion to 30 degrees (with objective evidence of painful motion at 25 degrees), extension to 30 degrees (with pain at 25 degrees), right and left lateral flexion to 30 degrees (with pain at 25 degrees), and right and left lateral rotation to 30 degrees (with pain at 25 degrees). After repetitive-use testing with three repetitions, the ranges of motion remained the same. The Veteran had localized tenderness of pain to palpation of the cervical spine, but no muscle spasms or guarding. X-rays showed straightening of the cervical spine, possibly positional or the result of muscular contraction. The neural foramina appeared severely narrowed on the left and mildly narrowed on the right, possibly positional. The examiner indicated that the Veteran had a diagnosis of cervical disc disease with radicular pain in the right upper extremity, diagnosed in 2008. The Veteran also had a VA examination for radiculopathy of the right upper extremity in November 2013. He reported having difficulty grasping things, dropping milk containers, and having pain in his right hand when writing and typing. His symptoms included moderate constant pain of the right upper extremity, moderate paresthesias and/or dysesthesias, and mild numbness. Elbow, wrist, grip, and pinch strength were normal, and a reflex examination showed normal deep tendon reflexes of the biceps, triceps, and brachioradialis. Sensation testing for light touch showed decreased sensation in the shoulder area (C5), inner/outer forearm (C6-T1), and hand/fingers (C6-8). The examiner indicated that the Veteran had moderate incomplete paralysis of the median nerve and mild incomplete paralysis of the upper radicular group (5th and 6th cervicals). In April 2014, the Veteran was noted to have an essentially normal neck range of motion without significant appreciated paraspinous muscle spasms. A June 2014 MRI showed a loss of the normal curvature of the cervical spine, which probably reflected underlying muscle spasms and/or underlying degenerative changes. There were also findings of disc bulging at multiple levels, most prominent at C5-6 and C6-7 where small herniations were evident. The Veteran was afforded a VA examination of the peripheral nerves in August 2015. He was noted to have constant mild pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity. The shoulder area and inner/outer forearm had normal sensation, and the hand/fingers had decreased sensation. The radial, medial, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular group (5th and 6th cervicals), and lower radicular group nerves were all found to be normal in the right upper extremity. The middle radicular group had mild incomplete paralysis. The examiner indicated that there were minimal to no changes from the November 2013 VA examination, and that findings were consistent with the natural progression of the median nerve paralysis and cervical disc disease. Also in August 2015, the Veteran's doctor, Dr. C.S., submitted a cervical spine disability questionnaire, in which he indicated that the Veteran had flare-ups of pain with shooting pains in the right arm approximately 5-10 times per month. Range of motion measurements included forward flexion to 30 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 50 degrees. After repetitive-use testing, the Veteran had increased sensitivity to movement and spasm. He also had localized tenderness of the all the cervical strap muscles and into the levator and trapezius. The Veteran's gait was abnormal due to muscle spasm, guarding, and low back issues. With regard to radiculopathy, the veteran had intermittent, moderate, dull pain of the right upper extremity. He also had moderate paresthesias and/or dysesthesias and numbness of the right upper extremity. Dr. C.S. indicated that the severity of the radiculopathy was moderate, with involvement of the upper radicular group and middle radicular group. He also reported that the Veteran had IVDS that entailed at least one week but less than two weeks of incapacitating episodes over the last 12 months. The Veteran testified in an October 2015 Board hearing that his neck and radicular pain required pain medication on a regular basis, and that he got migraine or tension headaches from the neck pain. He asserted that he got shooting pain his neck that went into his shoulders and arms. He stated that certain movements, like trying to look up or down, caused more pain and made "cracking and crunching" sounds. The Veteran stated that he had a TENS unit for his neck, and that he previously had injections in the neck. He stated that he could not do any activities due to neck pain, including bike riding, and that driving was hard. The Veteran noted that he when touched things with his right hand, he had sensation problems. He also noted that he had trouble grasping objects and dropped things approximately 3-4 times per week. Cervical Disc Disease The Veteran's cervical disc disease is rated under Diagnostic Codes 5243-5237 for Intervertebral Disc Syndrome (IVDS) and cervical strain. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four digits, 5243, represent the diagnostic code used to rate IVDS. The second four digits after the hyphen, 5237, represent the diagnostic code for rating a cervical strain. Diagnostic Code 5243 provides that IVDS (preoperatively or postoperatively) be rated under the General Rating Formula for Disease 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the Formula for Rating IVDS Based on Incapacitating Episodes, a 10 percent rating is warranted where there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted where there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted where there are 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 where there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. Diagnostic Codes 5235, vertebral fracture or dislocation; 5236, sacroiliac injury and weakness; 5237, lumbosacral or cervical strain; 5238, spinal stenosis; 5239, spondylolisthesis or segmental instability; 5240, ankylosing spondylitis; 5241, spinal fusion; and 5242, degenerative arthritis of the spine; are all rated under the following General Rating Formula for Disease and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242. With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5242. A 20 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent evaluation is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is assigned of unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. Id. Note (1): Evaluate any associated objective neurologic abnormalities, including but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Id. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Note (4): Round each range of motion measurement to the nearest five degrees. Id. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. Diagnostic Code 5242, degenerative arthritis of the spine, requires consideration of Diagnostic Code 5003, degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 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, Diagnostic Code 5003. The Board has carefully reviewed the evidence of record and finds that, for the entire increased rating period, the record does not demonstrate the requisite manifestations for a rating in excess of 20 percent for the service-connected cervical disc disease. For a 30 percent rating for a cervical spine disability under Diagnostic Codes 5237, forward flexion must be limited to 15 degrees or less. Alternatively, for a 40 percent rating under Diagnostic Code 5243, the evidence must show that the Veteran had incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. In this case, the weight of the competent and credible evidence shows that for the period of the appeal, forward flexion of the cervical spine was to at least 25 degrees, which is productive of a disability picture warranting no more than a 20 percent rating. As discussed above, the December 2009 VA examiner measured forward flexion to 25 degrees, with pain at 10 degrees but no additional limitations after three repetitions of movement; the November 2013 VA examiner measured forward flexion to 30 degrees, with pain at 25 degrees but no additional limitations after three repetitions of movement; and Dr. C.S. measured forward flexion in August 2015 as being to 30 degrees. While the August 2015 DBQ by Dr. C.S. checked off boxes for unfavorable ankylosis of the cervical spine and entire spine, he also provided findings that reflected motion to 30 degrees. As the presence of motion and Dr. C.S.'s own findings are inconsistent with his finding of unfavorable ankylosis, the Board finds the Veteran did not have ankylosis and a higher rating is not warranted. Furthermore, the Veteran did not experience IVDS with incapacitating episodes having a total duration of less than two weeks during the past twelve months. The only mention of IVDS in the evidence was Dr. C.S.'s August 2015 statement, in which he asserted that the Veteran had IVDS with incapacitating episodes having a total duration of at least one week but less than two weeks over the last 12 months. Such disability is productive of a 10 percent rating under Diagnostic Code 5243. The Board has considered whether a disability rating higher than 20 percent for the cervical disc disease is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. The Board notes, however, that the rating criteria are intended to take into account functional limitations, and therefore the provisions of 38 C.F.R. §§ 4.40 and 4.45 could not provide a basis for a higher evaluation. See 68 Fed. Reg. 51454 -5 (Aug. 27, 2003). In any event, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The VA examiners consistently found that the Veteran had no additional limitations on his range of motion after repetition of movement. The Board carefully considered the December 2009 VA examination that noted pain began at 10 degrees of flexion. In this regard, the Board considered whether a higher rating or staged rating could be given in light of that finding. The Court in Mitchell clarified, however, that prior caselaw equating painful motion to limited motion only in the limited context of Diagnostic Code 5003. Mitchell, 25 Vet. App. at 41. The Court specifically held that the prior cases did not equate painful motion to limitation of motion in the context of the evaluation of the condition under a Diagnostic Code whose evaluation criteria require limitation of motion. Id. Accordingly, the Court held that pain itself does not rise to the level of functional loss but rather must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance in order to constitute functional loss. Id. At 43. The Veteran has not demonstrated that her pain has affected the normal working movements of the body. The December 2009 examination noted that repetition did not cause additional limitation based on pain, fatigue, weakness or lack of endurance. The examiner also noted no functional loss due to the effects of pain. Furthermore, range of motion testing both prior to and after the December 2009 examination demonstrated greater ranges of motion, even considering the point where pain began. Thus, any additional limitation due to pain does not more nearly approximate a finding of forward flexion of the cervical spine being limited to 15 degrees or less, or incapacitating episodes having a total duration of at least 4 weeks in the past 12 months. See 38 C.F.R. § 4.45, 4.71a, Diagnostic Code 5242; DeLuca, 8 Vet. App. at 202; Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The current 20 percent rating contemplates the functional loss due to pain, excess fatigability, and less movement. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206-07. As will be discussed below, a separate rating has already been assigned for radiculopathy of the right upper extremity. Separate evaluations for other neurological disabilities are not warranted at this time, as the VA examiners and Dr. C.S. all indicated that the Veteran had no neurologic abnormalities aside from radiculopathy. Consideration has also been given to the potential application of the other diagnostic codes for disabilities of the spine. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. However, the Board finds no basis upon which to assign an evaluation in excess of 20 percent for the Veteran's cervical disc disability for the time period of the appeal. Diagnostic Code 5242, degenerative arthritis of the spine, refers to Diagnostic Code 5003, degenerative arthritis (hypertrophic or osteoarthritis). Diagnostic Code 5003, however, does not apply to this case, as the degenerative arthritis been rated on the basis of limitation of motion of the cervical spine. Diagnostic Code 5003 applies only where the limitation of motion is noncompensable under the appropriate codes, and in this case, the limitation of motion is compensable. In sum, the weight of the evidence is against the claim for a disability evaluation in excess of 20 percent for the service-connected cervical disc disability for the entire appeal period, and the appeal is denied. Radiculopathy of the Right Upper Extremity The Veteran's radiculopathy of the right upper extremity has been rated under Diagnostic Code 8515, for paralysis of the median nerve. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board has considered whether other rating codes are "more appropriate" than the ones used by the RO, Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995), and finds that the Veteran's radiculopathy of the right upper extremity is more appropriately rated under the criteria for impairment of the upper radicular group, under Diagnostic Code 8510, for the entire period on appeal. The November 2013 VA examiner and the Veteran's private physician, Dr. C.S., both found that the upper radicular group was involved. Notably, Diagnostic Code 8510 provides for a higher evaluation than Diagnostic Code 8516. In addition, the terms "major" and "minor" are used in the rating criteria to refer to the dominant or nondominant upper extremity. 38 C.F.R. § 4.69. Here, the Veteran self-reports as right-handed. Therefore, his right upper extremity is evaluated as major. Under Diagnostic Code 8510, which provides the rating criteria for paralysis of the upper radicular group (fifth and sixth cervicals), relevant to evaluating the Veteran's major (dominant) extremity, a 20 percent rating is assigned for mild incomplete paralysis of the upper radicular group, a 40 percent rating is assigned for moderate incomplete paralysis of the upper radicular group, a 50 percent rating is assigned for severe incomplete paralysis of the upper radicular group, and a 70 percent rating is assigned for complete paralysis of the upper radicular group (all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected) . The Board finds the Veteran is entitled to an evaluation of 40 percent, but no greater, for right cervical radiculopathy under Diagnostic Code 8510 for the entire period on appeal. The Veteran has consistently complained of pain, decreased sensation and numbness, and trouble grasping objects. STRs show that the Veteran had C5-C6 radiculopathy, the November 2013 VA examiner found that the Veteran had moderate incomplete paralysis of the median nerve and mild incomplete paralysis of the upper radicular group, and the Veteran's doctor, C.S., stated in August 2015 that the Veteran had moderate radiculopathy with involvement of the upper radicular group and middle radicular group. As such, affording the Veteran reasonable doubt, the Board finds the Veteran is entitled to an evaluation of 40 percent, but no greater, for radiculopathy of the right upper extremity under Diagnostic Code 8510 for the entire period on appeal. See 38 C.F.R. § 4.7. His symptom of inability to grasp items and dropping 3-4 things per week represents symptoms beyond that which are wholly sensory. Such manifestations, along with descriptions of moderate pain, decreased sensation, and numbness more closely approximates moderate symptoms. The evidence weighs against a higher rating of 50 percent, which is designated for severe incomplete paralysis. In the absence of clinical evidence demonstrating severe incomplete paralysis of the right upper extremity due to cervical spine disability, assignment of an increased evaluation above the aforementioned rating is not warranted. At no point was the Veteran's disability characterized by more than moderate disturbances and pain, and he has always retained the ability to move and use his shoulder, arm, hand, and fingers. Such symptoms, while significant, do not reveal severe symptoms of incomplete paralysis. Furthermore, there is no medical evidence of record to warrant the assignment of a higher evaluation under any applicable Diagnostic Code. Severe incomplete paralysis has not been demonstrated at any time in this case. In assessing the symptoms associated with the Veteran's right upper extremity radiculopathy, the record reflects reports of various levels of pain and decreased sensation involving the right shoulder and hand. Evidence currently of record does not demonstrate symptoms such as pain, numbness, or functional loss greater than moderate incomplete paralysis. Moreover, the Veteran cannot be compensated twice for the same symptomatology. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.14. Thus, in resolving all reasonable doubt in the Veteran's favor, a rating of 40 percent, but no greater, for the entire period on appeal for radiculopathy of the right upper extremity is warranted under Diagnostic Code 8510. Extraschedular Consideration The Board has considered whether referral for an "extraschedular" evaluation is warranted. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. 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 the service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate a Veteran's level of disability and symptomatology and is found inadequate, it must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step, a determination of whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence fails to show unique or unusual symptomatology regarding the Veteran's service-connected cervical disc disease or radiculopathy of the right upper extremity that would render the schedular criteria inadequate. The Veteran's symptoms, including pain, pain on motion, limited range of motion, decreased sensation and numbness, and difficulty grasping items are contemplated in the ratings assigned; thus, the application of the Rating Schedule is not rendered impractical. Moreover, the Veteran has not argued that his symptoms are not contemplated by the rating criteria; rather, he merely disagreed with the assigned disability ratings for his levels of impairment. In other words, he did not have any symptoms from his service-connected disabilities that are unusual or different from those contemplated by the schedular criteria. Moreover, the Veteran has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Accordingly, the Board finds that referral for consideration of an extraschedular rating is not warranted, as the manifestations of the Veteran's cervical disc disease and radiculopathy of the right upper extremity are considered by the schedular rating assigned. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. ORDER Service connection for a thoracic or lumbar spine disability is granted. For the entire period of appeal, a rating in excess of 20 percent for the cervical disc disease is denied. For the entire period of appeal, a rating of 40 percent for radiculopathy of the right upper extremity under Diagnostic Code 8510 is granted. REMAND The Veteran submitted a timely notice of disagreement in January 2016 on the issues of entitlement to service connection for a left shoulder disability, carpal tunnel syndrome, a bilateral wrist disability, a bilateral hand disability, a peptic ulcer, hypertension, an eating disorder, malnutrition, and entitlement to a special monthly compensation based on loss of use. A Statement of the Case (SOC) has not been issued. As such, the Board is required to remand the issues for issuance of an SOC. Manlincon v. West, 12 Vet. App. 238 (1999). With regard to the issue of entitlement to a TDIU, any decision on the service connection claims being remanded, and the claim granted herein, may affect the claim for a TDIU. Any grant of a pending service connection claim could significantly change the adjudication of the TDIU issue because such a grant could increase the Veteran's overall combined disability percentage. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Consideration of entitlement to a TDIU must therefore be deferred until the intertwined issues are resolved or prepared for appellate consideration. See Harris, 1 Vet. App. at 183 (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Accordingly, the case is REMANDED for the following action: 1. Issue an SOC to the Veteran addressing the issues of service connection for a left shoulder disability, carpal tunnel syndrome, a bilateral wrist disability, a bilateral hand disability, a peptic ulcer, hypertension, an eating disorder, malnutrition, and entitlement to a special monthly compensation based on loss of use. The Veteran should be advised of the time limit in which to file a Substantive Appeal. Then, if the appeal is timely perfected, the issues should be returned to the Board for further appellate consideration, if otherwise in order. 2. Afterwards, the AOJ should then take such additional development action as it deems proper with respect to the claim for TDIU. When the development requested has been completed, the case should again be reviewed on the basis of the additional evidence and readjudicated. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case. A reasonable period of time must be allowed for a response before the case is returned to the Board for further review. 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). ______________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs