Citation Nr: 1620528 Decision Date: 05/19/16 Archive Date: 05/27/16 DOCKET NO. 10-21 338 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an initial disability rating in excess of 10 percent for a service-connected low back disability. 3. Entitlement to an initial disability rating in excess of 10 percent for a service-connected cervical spine disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Boyd Iwanowski, Associate Counsel INTRODUCTION The Veteran served on active duty from July 2003 to August 2003, from March 2004 to July 2005, and from June 2007 to June 2008. He also had additional periods of unverified service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In March 2015, the claims were remanded for new VA examinations and to obtain the Veteran's most recent treatment records. Records dated to March 2015 appear in the claims file and in April 2015 and June 2015, the Veteran underwent VA examinations. The Board finds that the Veteran substantially complied with the remand directives and therefore, an additional remand is not required pursuant to the holding in Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 2. For the entire period on appeal, the Veteran's service-connected low back disability has been manifested by forward flexion greater than 60 degrees, pain and tenderness; the evidence does not demonstrate abnormal gait, abnormal spinal contour or ankylosis. 3. For the entire period on appeal, the Veteran's service-connected cervical spine disability has been manifested greater than 40 degrees, pain and tenderness; the evidence does not demonstrate abnormal gait, abnormal spinal contour or ankylosis. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. The criteria for an initial disability rating in excess of 10 percent for mechanical low back strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5237 (2015). 3. The criteria for an initial disability rating in excess of 10 percent for mechanical cervical muscle strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5237 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Compliant VCAA notice was provided in May 2008. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. Additionally, VA examinations were conducted that provide the information necessary to properly rate the Veteran's disabilities. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Disability Ratings Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history; reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of evidence for and against the issue, all reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). a. PTSD During the period on appeal the Veteran's PTSD has been rated as 30 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under DC 9411, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder the rating agency will consider the level of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Court has held that the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Another factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flattened affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF score of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. In November 2008, the RO granted service connection for PTSD and assigned a 10 percent initial rating based on findings at an July 2008 VA examination. At that examination, the Veteran indicated mild intrusive thoughts or memories of his combat experiences. He noted flashbacks occurring once every two weeks. He reported a "slight level" of estrangement from family members and his affect was noted to be restricted slightly. He indicated some hypervigilance and being startled by loud noises. He noted irritability toward others and problems with sleep initiation that was classified as mild. It was noted that the PTSD had not remitted, although the nightmares had been in remission for about 4 months. Suicidal or homicidal thoughts were denied. The examiner assigned a GAF score of 65. At the time of the July 2008, VA examination, the Veteran's PTSD was classified as mild and the examiner noted that "there would be a mild decrease in work efficiency and ability to perform occupational tasks only during periods of significant stress." In January 2010, the Veteran underwent another VA examination. He presented as mildly anxious. It was noted he made good eye contact and was cooperative with the interview process. The examiner opined that he might be sleep deprived. The Veteran reported that at the time of the previous examination in July 2008, he was drinking alcohol three times a week, approximately 10-15 beers per occasion. It was noted the Veteran had not sought counseling since the last examination. The Veteran stated his symptoms had gotten worse and that memories of in-service trauma were coming into his mind more frequently. He reported that "getting through the activities of everyday life seem[ed] to be more of a strain." He indicated continuing to work at a home improvement store 50 hours a week and to live with his wife and 3-month-old daughter. He indicated having been promoted to manager at his store in February 2009. The Veteran reported he currently supervised people. With regard to his alcohol use, the Veteran stated that he now drank only twice per week and had only three to four beers per occasion. It was noted the Veteran was not taking any medication. At night, he could fall asleep without difficulty. He related having nightmares about twice per week and that he would wake up from dreams about combat incidents on deployments. He stated that twice a day he would have "unwelcome recollections of his deployment incidents" come into his mind. He indicated loud noises startled him and reminded him of his time overseas. He avoided Middle-Eastern looking people when they would come into the store. He avoided crowds and remained alert to possible threats in public and while driving. He reported some emotional numbing and that he did not see as much of his friends as he used to. The examiner reported that his speech was logical and related, with no indication of hallucinations, delusions, or formal thought disorder. There was no flight of ideas or loosening of associations. His memory and concentration were noted to be adequate. The examiner opined that the Veteran continued to show a mild level of impairment that was similar to that shown in January 2010. He was functioning well at work and with his family and did not feel the need for mental health treatment. The examiner assigned a GAF score of 62. In his May 2010 Form 9, the Veteran cited depression, anxiety, irritability and sleep disturbance and opined that he believed he met or exceeded the 30 percent criteria for PTSD. In addition, he reported having difficulty establishing and maintaining effective work and social relationships. He communicated his belief that his alcohol dependence was due to his PTSD which affected his social and family life. In a September 2011 rating decision, the RO increased the Veteran's initial disability rating for PTSD to 30 percent based on evidence of chronic sleep impairment and depressed mood. Treatment records around that time noted the Veteran was taking medication for depression and insomnia. In October 2012, the Veteran sought VA treatment seeking to reestablish care for PTSD and insomnia. In a January 2014 treatment record, the Veteran reported having anger issues, mood swings and that he felt depressed. He stated he had periods of anxiety, but continued to work 60 hours per week. It was noted that the Veteran drank alcohol socially and that it had been problematic in the past. A treatment record in February 2014 indicated the Veteran was "doing fine" and his medication was working. He noted being less anxious and less depressed and having been on a new medication for three weeks. He anticipated seasonal stress at work. A treatment record dated in September 2014 indicated the Veteran was "doing well." It was indicated he was busy and had recently bought a home. He indicated he was "not depressed much lately" and generally slept six to seven hours. It was noted his anger was better controlled, but that he avoided crowds and loud noises were distracting. In March 2015, the Board remanded the claim for a new VA examination. The examiner noted the Veteran's symptomatology demonstrated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported living with his wife and three young children. He indicated problems with anger outbursts at home and stated that he sometimes threw objects in anger. The Veteran reported having few friends and tending to socially isolate when not at work. The Veteran noted anxiety when driving in traffic and hypervigilance related to roadside objects. He reported feeling anxious and irritable around others who appeared to be of Middle Eastern decent. The Veteran reported he continued to work 55 hours per week. He reported enjoying his job and that he had positive performance ratings. He denied missing any days of work in the previous 12 months due to mental health related concerns. However, he had received a written counseling in the past year for an anger outburst toward another employee. He indicated investing himself heavily in his work as a way of coping with anxiety and reminders of events related to deployments. The examiner noted depressed mood, anxiety, suspiciousness, chronic sleep impairment and mild memory loss caused by the Veteran's PTSD. It was noted the Veteran appeared tired, but he was adequately groomed and appropriately dressed. He was alert and fully oriented and his speech was normal. The Veteran indicated his mood was "on and off" and that his wife said he was angry all the time. He reported no phobias or panic attacks. He endorsed feeling nervous, anxious or on edge much of time and feeling excessive worry. He indicated having trouble relaxing and being so restless that it was hard to sit still. He reported becoming easily annoyed or irritable and feeling afraid as if something awful might happen. The Veteran reported low mood much of the time with limited interest in activities, but denied thoughts of harm to self or others. He indicated sleeping six to seven hours and experiencing nightmares 2 to 3 times per week. No obsessive or ritualistic behavior was noted and there was no evidence of hallucinations, delusions or signs of a thought disorder. The examiner assigned a GAF score of 62. After review of the evidence of record, the Board finds that a higher evaluation than 30 percent for PTSD is not warranted. The Board finds that during the entire period on appeal the Veteran's PTSD most closely approximates the currently assigned 30 percent rating. In that regard, the Veteran did not demonstrate the symptoms associated with higher ratings during the time period, nor did he demonstrate other symptoms of similar severity, frequency, and duration. The Board has considered the Veteran's assertions as to his symptomatology and the severity of his condition, but, to the extent he believes he is entitled to a higher rating, concludes that the findings during medical evaluation are more probative than the Veteran's lay assertions to that effect. Accordingly, the preponderance of the evidence is against the Veteran's claim, and an evaluation in excess of 30 percent for PTSD is denied. b. The Spine The Veteran's low back and cervical spine disabilities are evaluated under the General Rating Formula for Diseases and Injuries of the Spine, DC 5237. Pursuant to this formula, an evaluation of 10 percent 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. An evaluation of 20 percent 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. A 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine is 30 degrees or less; or, when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating requires unfavorable ankylosis of the entire spine. Any associated objective neurologic abnormalities, including but not limited to bowel or bladder impairment, are to be evaluated separately under the appropriate diagnostic codes. 38 C.F.R. § 4.71a, Note (1). Therefore, as part of the current appeal, the Board has considered any separately evaluated objective neurologic abnormalities associated with the Veteran's back disabilities. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 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 may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2015); see also 38 C.F.R. §§ 4.45, 4.59 (2015). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In November 2008, the RO granted service connection for mechanical low back strain and assigned a 10 percent rating. In addition, the RO granted service connection for mechanical cervical muscle strain and assigned a noncompensable rating. Both ratings were based on a July 2008 VA examination report. At the July 2008 VA examination, forward flexion of the thoracolumbar spine was to 80 degrees, extension was to 30 degrees and lateral flexion and rotation were to 30 degrees. Combined range of motion in the low back was to 230 degrees. Mild pain, mild weakness and fatigue were noted after three repetitions. As to the cervical spine, forward flexion and posterior extension were to 45 degrees. Lateral flexion was to 30 degrees and lateral rotation was to 85 degrees. There was no weakness, fatigue or incoordination noted following repetition. X-rays showed subluxation of C-6 on C-7. In February 2010, the Veteran underwent another VA examination. Constant pain was noted in the lower lumbar area without radicular symptoms. It was noted the Veteran was seeking treatment from a chiropractor, but he was not taking medication. Flare-ups were caused by sitting or standing over 20 minutes. Dislocation and subluxation were denied. As to the effect on daily activities, it was noted the Veteran could do everything he did before but with more pain. The Veteran denied problems with loss of balance or falls. X-rays showed a normal lumbosacral spine. The examiner noted that the Veteran's back pain was actually SI joint pain and significant tenderness was present overlying the SI joints, within the soft tissues. Range of motion was full with pain. As to the cervical spine, constant neck pain was noted and the Veteran related his neck would pop when he turned his head occasionally. It was noted there were no radicular symptoms, although the Veteran reported experiencing pain in the shoulders when his neck was sore. Sitting, standing and strenuous work were said to cause flare-ups. Range of motion was normal and no soft tissue, bony tenderness or deformity was noted, although mild tenderness was present overlying the levator scapula attachment at the scapular borders. The examiner noted ligament laxity as noted in the x-ray report when demonstrated subluxation of C-6 on C-7 which was unchanged from x-ray in July 2008. In the April 2010 statement of the case, the RO continued a 10 percent rating for mechanical low back strain based on tenderness not resulting in abnormal gait or spinal contour. The RO also increased the rating for the cervical spine to 10 percent given evidence of tenderness. In his May 2010 Form 9, the Veteran indicated his back pain affected him on a daily basis and slowed him down in everyday activities, especially work. He indicated understanding that he could flex to a certain degree, but he indicated he could do it with an "overwhelming amount of pain." He indicated his back pain was very severe and getting worse each year; he indicated he was only 26 years old and classified his pain as "unbearable. VA treatment records dated in May 2014 showed treatment for low back pain. The Veteran noted only mild discomfort in the low back. He indicated no complaints of neck pain. X-rays from April 2014 were reviewed and showed lumbarization of S1 with no acute fracture, subluxation or bone destruction. Disc spaces were well-preserved. The soft tissues appeared unremarkable. In March 2015, the Board remanded the claims for VA examinations to determine the current severity of the Veteran's back disabilities. In April 2015, the Veteran underwent an examination. The Veteran reported constant low back pain without radiculopathy. He denied flare-ups. No neurological disorders were noted. He indicated most of the pain occurred while sitting and he would take over-the-counter pain killers. He indicated when lifting and carrying at work as an Assistance Manager of a store, he would experience short periods of increase in pain to his low back. He indicated "working through it." Range of motion was normal and no functional loss was shown after repetition. There was minimal tenderness noted over the mid-spine around L5. Muscle spasm and guarding were denied. There was no evidence of ankylosis of the spine. It was noted that the low back condition did not materially affect the Veteran's ability to work. On examination of the cervical spine, cervical strain was identified. Similar to his low back complaints, the Veteran noted constant pain that would become temporarily worse after lifting and carrying at work. He noted he was able to do the lifting required at work, but he would momentarily have more neck discomfort. He denied other flare-ups. Range of motion was normal and the Veteran did not report having any functional loss or functional impairment of his cervical spine. Localized tenderness, guarding and muscle spasm were denied. There was no evidence of ankylosis or any neurological abnormalities, such as bowel or bladder problems. It was noted that the Veteran's cervical spine disability did not affect his ability to work. Upon review of the evidence as a whole, the Board finds that the preponderance of the evidence is against granting the Veteran's claims for disability ratings greater than 10 percent for either his low back or cervical spine disability. The medical evidence of record does not demonstrate the limitation of motion or functional loss necessary to warrant 20 percent ratings. In addition, the evidence does not show muscle spasms, guarding or abnormal gait or spinal contour. In summary, the evidence of record does not more nearly approximate the criteria for 20 percent ratings. Accordingly, a higher 20 percent rating is not warranted under DC 5237 under the General Rating Formula for Diseases and Injuries of the Spine for either service-connected back condition, and the benefit-of-the-doubt standard does not apply. 38 U.S.C.A. § 5107(b) 38 C.F.R. §§ 4.7, 4.71a, DC 5237. The Board has considered the provisions of 38 C.F.R. §§ 4.40 and 4.4, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206-07. Such symptomatology is not shown in the record and the Veteran is able to do lifting and carrying as necessary at his employment with a temporary increase in pain. The Veteran finds that the Veteran's primary symptoms for both his low back and cervical spine conditions, to include pain and tenderness , are already contemplated by the assigned 10 percent ratings and a higher rating is not warranted. 38 C.F.R. §§ 4.40, 4.45 (2014); DeLuca, 8 Vet. App. at 204 -06. Consideration has been given as to whether a higher disability evaluation could be assigned under DC 5243, intervertebral disc syndrome. In this regard, intervertebral disc syndrome has not been identified and there is no indication the Veteran was prescribed bed rest by a physician. Therefore, a higher rating based upon incapacitating episodes under DC 5243 is not appropriate. See 38 C.F.R. § 4.71a, DC 5243 (2015). As the preponderance of the evidence is against the Veteran's claims for increased ratings for his service-connected back disabilities, the benefit-of-the-doubt doctrine is inapplicable and the claims must be denied. 38 U.S.C.A. § 5107. III. Other Considerations The Board has also considered whether referral for extraschedular consideration is warranted for the Veteran's PTSD or back disabilities. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence for PTSD, low back strain and cervical back strain. Thus, his disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun, 22 Vet. App. at 115. The Board also notes that the Veteran has not been hospitalized for his PTSD or either back condition. In addition, none of his conditions have been shown to cause marked interference with his employment as an Assistant Manager. Accordingly, there is no basis for referral of either claim for extraschedular consideration and referral is not warranted. As a final matter, the Board acknowledges that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. Here, the evidence reflects that the Veteran has been working fulltime throughout the appeal period. There is no evidence that he is unable to maintain or sustain substantially gainful employment due to any of his service-connected disabilities. Accordingly, the Board finds that a claim for a TDIU has not been raised by the record, and no further action pursuant to Rice is necessary. (CONTINUED ON NEXT PAGE) ORDER An initial rating in excess of 30 percent for PTSD is denied. An initial rating in excess of 10 percent for mechanical low back strain is denied. An initial rating in excess of 10 percent for mechanical cervical muscle strain is denied. ____________________________________________ M. Tenner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs