Citation Nr: 1622290 Decision Date: 06/03/16 Archive Date: 06/13/16 DOCKET NO. 14-15 882 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an initial disability rating higher than 10 percent for service-connected status-post traumatic arthrosis of the right wrist. 2. Entitlement to an initial disability rating higher than 10 percent for service-connected degenerative arthritis of the cervical spine. 3. Entitlement to a total rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Meawad, Counsel INTRODUCTION The Veteran served on active duty from June 1975 to July 1979 and from April 1984 to February 2010. This matter is before the Board of Veterans' Appeals (Board) on appeal of an April 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The record reasonably raises a claim for a total disability rating based on individual unemployability (TDIU), which is not a separate claim, but a part of the claim for increase on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. The Veteran's status-post traumatic arthrosis of the right wrist has been manifested by favorable ankylosis in 20 to 30 degrees dorsiflexion. 2. Prior to February 25, 2016, the Veteran's degenerative arthritis of the cervical spine has been manifested by forward flexion of 45 degrees and neurological impairment of both upper extremities. 3. From February 25, 2016, the Veteran's degenerative arthritis of the cervical spine has been manifested by forward flexion of 20 degrees; neurological impairment of both upper extremities; and incapacitating episodes prescribed by a physician and treated by a physician having a total duration of at least two weeks but less than four weeks during a 12-month period. 4. Service connection is in effect for sleep apnea, benign prostatic hypertrophy, degenerative arthritis of the right acromioclavicular joint, status-post traumatic arthrosis of the right wrist, degenerative arthritis of the cervical spine, degenerative arthritis of the lumbar spine, right knee degenerative medial meniscus, tinnitus, sinusitis, gastroesophageal reflux disease, cholinergic urticaria, meibomian gland dysfunction with dysfunctional tear syndrome, otitis media of the left ear, nasal polyps, neck scar, abdominal scars, status-post arthroscopic surgery scars of the right shoulder, acne and neurological abnormalities of the right and left upper extremities. Sleep apnea has been assigned a 50 percent disability rating and the combined rating for the service-connected disorders is 90 percent. 5. The Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent disability rating, but no more, for status-post traumatic arthrosis of the right wrist were met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.73, Diagnostic Code 5215 (2015). 2. Prior to February 25, 2016, the criteria for an initial disability rating in excess of 10 percent for degenerative arthritis of the cervical spine, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015). 3. From February 25, 2016, the criteria for a 20 percent disability rating, but no more, for degenerative arthritis of the cervical spine have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015). 4. The criteria for a separate compensable disability rating for radiculopathy of the right upper extremity associated with the cervical spine disability, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015). 5. The criteria for a separate compensable disability rating for radiculopathy of the left upper extremity associated with the cervical spine disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015). 6. The criteria for TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Right Wrist The Veteran's service-connected right wrist disability is currently rated 10 percent under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5215. Limitation of motion of the wrist is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5214 and 5215, which distinguish between the major (dominant) and minor (non-dominant) extremity. In this case, the medical evidence of record clearly reflects that the Veteran is right-handed. Thus, the rating for his right wrist disability is based on the criteria for evaluating disabilities of the major (dominant) extremity. Under Diagnostic Code 5215, either dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm warrant a 10 percent rating. Diagnostic Code 5214 provide up to a 50 percent rating based on levels of ankylosis of the wrist. Favorable ankylosis in 20 to 30 degrees dorsiflexion warrants a 30 percent rating; any other position, except favorable warrants a 40 percent rating; and unfavorable, in any degree of palmar flexion or with ulnar or radial deviation warrants a 50 percent rating. 38 C.F.R. § 4.71a. The Rating Schedule provides guidance by defining full range of motion of the wrist as 0 to 70 degrees dorsiflexion, 0 to 80 degrees palmer flexion, 0 to 45 degrees ulnar deviation, and 0 to 20 degrees radial deviation. 38 C.F.R. § 4.71a, Plate I. During the October 2009 VA examination, the Veteran's right wrist was diagnosed as status-post right wrist traumatic arthrosis. The examiner stated that the subjective factors were reoccurring right wrist pain, which increased with physical activity, and his objective factors are reduced range of motion with pain. The Veteran reported weakness, swelling, giving way, tenderness, pain, and limited range of motion. He reported flare-ups precipitated by physical activity approximately two times per month, lasting two days, with a severity level of 9 out of 10. The flare-ups were alleviated by rest, heat, and brace use. During the flare-ups, he experienced functional impairment of pain and weakness in the right wrist, and limitation of motion of the joint. Treatment included steroid injections, physical therapy, occupation therapy, heat, rest, and prescribed brace. X-rays of the right wrist were within normal limits. Range of motion of the right wrist was 40 degrees dorsiflexion and 60 degrees palmar flexion. There was no additional limitation of motion with repetition, but joint function was additionally limited by pain after repetitive use. During the February 2016 hearing before the Board, the Veteran stated that his right wrist problems forced him to use his left hand more and invest in voice recognition software. Using his right wrist caused pain, weakness, and fatigue and he would have to use wrist braces due to fatigability, which were prescribed. In order to recover from a flare-up, the Veteran would need to wear a hard brace and rest the wrist for a week. In a February 2016 VA examination, the Veteran reported having to wear a soft brace regularly to protect his right wrist, and a hard brace when he developed pain and weakness due to normal daily use. His functional limitations were less movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, in addition to monthly occurrences of pain and weakness experienced from normal daily activities that caused the Veteran to put on a hard brace for a week until the pain and weakness subsided. He was unable to flex his wrist backwards without extreme pain, and could not pick up or move anything greater than five pounds, without first bracing the right wrist or just using the left hand. The right wrist range of motion was 45 degrees palmar flexion and 20 degrees dorsiflexion. Repetitive-use testing could not be performed due to severe pain. Range of motion testing produced continuous pain that if not stopped quickly, would result in at least a week of chronic pain. Pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups. An estimated range of motion was not feasible as the Veteran had loss of use of the right wrist due to severe pain. His right wrist had to be immobilized with a hard brace until the pain subsided. He also had a reduction in muscle strength with a 4 out of 5 in flexion and 3 out of 5 in extension. Based on range of motion alone, manifestations of the right wrist does not meet the criteria for a rating higher than 10 percent as it was not found to have ankylosis on examination and the range of motion was at worst 45 degrees palmar flexion and 20 degrees dorsiflexion. However, given that the functional limitations as described by the Veteran and VA examiners associated with use of the right wrist, the evidence shows that the Veteran's right wrist disability approximates a finding of favorable ankylosis in 20 to 30 degrees dorsiflexion by analogy based on his level of disability during flare-ups. 38 C.F.R. § 4.7 (2015). The Veteran is unable to use his right wrist for normal daily activities and has monthly occurrences of pain and weakness experienced from normal daily activities, that cause the Veteran to put on a hard brace for a week until the pain and weakness subsided. During these flare-ups, the examiner stated that the Veteran essentially loses the use of the right wrist due to severe pain. The Board finds that having to place his wrist in a hard brace due to pain and weakness is analogous to favorable ankylosis and a 30 percent disability rating is warranted. The criteria for the next higher rating requires ankylosis in any other position except favorable. As the right wrist disability only approximates a 30 percent rating, a higher rating is not warranted. Additionally, there is no evidence that the Veteran must immobilize his right wrist in an unfavorable angle during flare-ups. Therefore, the criteria for a rating higher than 30 percent are not met. In sum, a higher 30 percent schedular rating, but no more, for a right wrist disability is warranted. However, the preponderance of the evidence is against a schedular rating in excess 30 percent at any time during the appeal period. See 38 U.S.C.A. § 5107(b); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Cervical Spine The Veteran's service-connected cervical spine disability is currently rated 10 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Spine disabilities are evaluated under Diagnostic Codes 5235 to 5243 using the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) unless evaluating using the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based On Incapacitating Episodes (Formula for Rating IVDS). Under the General Rating Formula, the criteria for a rating of 10 percent are forward flexion of the cervical spine greater than 30 degrees but not greater than 40 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. The criteria for a rating of 20 percent are forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, 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. The criteria for a 30 percent rating are forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. The criteria for a 40 percent rating are unfavorable ankylosis of the entire cervical spine. The criteria for a 100 percent rating are unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. Any associated objective neurologic abnormalities are evaluated separately under an appropriate Diagnostic Code. Id. at Note (1). Under the Formula for Rating IVDS, incapacitating episodes having a total duration of at least one week, but less than two weeks during 12 months are rated at 10 percent. Incapacitating episodes having a total duration of at least two weeks, but less than four weeks during 12 months are rated at 20 percent. Incapacitating episodes having a total duration of at least four weeks, but less than six weeks during 12 months are rated at 40 percent. Incapacitating episodes having a total duration of at least six weeks during 12 months are rated at 60 percent. 38 C.F.R. § 4.71a, Formula for Rating IVDS. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). During the October 2009 VA examination, the Veteran reported having symptoms of stiffness, decreased motion, paresthesia, and numbness. He reported having constant pain in his neck that traveled to down both shoulders, which was severe and could be exacerbated by physical activity and stress. His symptoms were relieved by rest, medication and a neck brace. During flare-ups, he experienced functional impairment with pain, limited range of motion, and difficulty with daily functions. Limitation of motion of the cervical spine was due to a spinal fusion at C5-6 in January 2004. He had been treated with surgery, chiropractic visits, traction, tens unit, medication, and radio frequency thermal coagulation. He denied having any incapacitation and his gait was normal. Upon examination of the cervical spine, there was no evidence of radiating pain on movement, muscle spasm, weakness, loss of tone, and atrophy of the limbs. The examination revealed tenderness in the neck area and there was evidence of guarding. There was no ankylosis of the cervical spine. Range of motion testing revealed flexion, extension, right and left lateral flexion were to 45 degrees and right and left rotations were to 80 degrees. X-rays revealed degenerative arthritis, narrowing of C5-C6 intervertebral disc space, and an anterior surgical plate present for fusion of C5 and C6. Neurological examination of the upper extremities was normal and there were no signs of cervical intervertebral disc syndrome (IVDS), with chronic and permanent nerve root involvement. VA treatment records show that the Veteran was treated for cervical radiculopathy at C7 nerve root treated, with injection in November 2010 and January 2011. In December 2010, the Veteran was treated for diagnoses of right C6-7 protrusion, with uncinate hypertrophy, foraminal stenosis, and right C7 radicular arm pain, status post C5-6 anterior cervical diskectomy and fusion. In June 2011, the Veteran underwent surgical revision, with removal of C5-6 anterior plate and decompression and fusion of C6-7. In May 2013, the Veteran's bilateral greater occipital neuralgia was treated with a bilateral greater occipital cryoablation under ultrasound guidance. During the February 2016 hearing before the Board, the Veteran reported that he would wake up due to pain from his cervical spine. The Veteran also reported that his two disc fusions in 2004 and 2011 caused such degeneration that he now had nerve root problems. His cervical spine problems also caused nerve root pain down to his right hand, which required a foraminotomy in December 2015 and a yearly thermal ablation. He also had nerve root pain down his left side. In a February 2016 VA examination, the Veteran was diagnosed with IVDS and had incapacitating episodes of at least two weeks, but less than four weeks within the past 12 months. The most recent magnetic resonance imaging scan in October 2015 revealed degenerative disc disease, degenerative joint disease, and bilateral radiculopathy. Range of motion testing revealed forward flexion to 20 degrees, extension to 20 degrees, right lateral flexion to 15 degrees, left lateral flexion to 20 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 20 degrees. There was no change in range of motion with repetitions. Contributing factors for functional limitation were of less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, interference with sitting and standing, and interference with sleep. Sensory examination of the upper extremities were abnormal and nerve groups involved were the upper radicular group affecting the right and left upper extremities and the middle and lower radicular groups affecting the right upper extremity. The examiner found that the Veteran's radiculopathy was caused by osteoarthritis and spinal fusions at C5-7 and occipital neuralgia, which was an adverse effect of two spinal fusion surgeries. Prior to February 25, 2016 Prior to February 25, 2016, based on range of motion testing, the evidence does not demonstrate that the Veteran had limitation of motion that would result in a disability rating higher than 10 percent. At no point during this time period does the evidence of record demonstrate forward flexion of the cervical spine less than 30 degrees; the combined range of motion of the thoracolumbar spine less 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. There is also no evidence of ankylosis, favorable or unfavorable, of the cervical spine. As such, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected degenerative arthritis of the cervical spine is not warranted under the General Rating Formula. 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Board has also determined that the assignment of a higher rating is not warranted under the Formula for Rating IVDS, as treatment records and the October 2009 VA examination report did not document IVDS with incapacitating episodes having a total duration of at least two weeks but less than four weeks at any point during the appeal period. The Board further finds that there is no basis for the assignment of a higher rating based on consideration of functional loss of the cervical spine prior to February 25, 2016. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); Deluca v. Brown, 8 Vet. App. 202, 204-06 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Indeed, as noted, even with his complaints of pain, flare-ups, and functional limitation, the Veteran has not demonstrated loss of flexion to 30 degrees or less or a combined range of motion of the cervical spine of 170 degrees or less. The Board has considered the factors regarding pain and functional loss noted above. Here, however, the medical findings do not show that painful motion or limitation of motion on repetitive use or during flare-ups results in functional loss warranting the assignment of any increased evaluation prior to February 25, 2016. Beginning February 25, 2016 For the time period from February 25, 2016, the Board finds that the Veteran's disability meets the criteria for a disability rating of 20 percent. The February 2016 VA examination shows forward flexion of the cervical spine was to 20 degrees with and without repetition, which meets the criteria for a 20 percent rating for the cervical spine based on limitation of motion under the General Rating Formula. 38 C.F.R. § 4.71a. Based on range of motion testing from February 25, 2016, the evidence does not demonstrate that the criteria for the next higher rating have been met for the cervical spine. At no point during time period does the evidence of record demonstrate forward flexion of the cervical spine less than 15 degrees and there is also no evidence of ankylosis, favorable or unfavorable, of the cervical spine. As such, the Board finds that a rating in excess of 20 percent for the Veteran's service-connected degenerative arthritis of the cervical spine is not warranted under the General Rating Formula. 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Board has also determined that the assignment of a higher rating is not warranted under the Formula for Rating IVDS from February 25, 2016. Although the February 2016 VA examiner noted that the Veteran had IVDS which caused incapacitating episodes requiring bed rest for at least 2 weeks, but less than 4 weeks within the past 12 months, the evidence does not show that the Veteran required at least 4 weeks of bed rest. The Board further finds that there is no basis for the assignment of a higher rating based on consideration of functional loss of the cervical spine from February 25, 2016. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); Deluca v. Brown, 8 Vet. App. 202, 204-06 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Indeed, as noted, even with his complaints of pain, flare-ups, and functional limitation, the Veteran has not demonstrated loss of flexion to 15 degrees or less. The evidence reflects that the 20 percent rating properly compensates him for the extent of functional loss resulting from symptoms like painful motion, less movement than normal, and fatigability. The Board has considered the factors regarding pain and functional loss noted above. Here, however, the medical findings do not show that painful motion or limitation of motion on repetitive use or during flare-ups results in functional loss warranting the assignment of an evaluation in excess of 20 percent from February 25, 2016. In accordance to Note 1 under the General Rating Formula for Diseases and Injuries of the Spine, any associated objective neurologic abnormalities are evaluated separately under an appropriate Diagnostic Code. The Board finds that the evidence supports a finding for separate compensable evaluations for neurologic abnormalities of the right and left upper extremities associated with the Veteran's cervical spine disability. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Throughout the appellate period, the Veteran exhibited evidence of radiculopathy of the upper extremities, the right being worse than the left, and was treated for this condition. 38 C.F.R. § 4.124a, Diagnostic Codes 8510 to 8513. As such, rating the Veteran's cervical spine disability under the General Rating Formula is more advantageous for the Veteran. Extraschedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2015). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). 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, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the assigned ratings inadequate. The Veteran's service-connected right wrist and cervical spine were evaluated as a disease or injury of the wrist and spine pursuant to 38 C.F.R. § 4.71a, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by these disabilities. Id. The Veteran's status-post traumatic arthrosis of the right wrist has been manifested by favorable ankylosis in 20 to 30 degrees dorsiflexion. Prior to February 25, 2016, the Veteran's degenerative arthritis of the cervical spine has been manifested by forward flexion of 45 degrees and neurological impairment of both upper extremities. From February 25, 2016, the Veteran's degenerative arthritis of the cervical spine has been manifested by forward flexion of 20 degrees; neurological impairment of both upper extremities; and incapacitating episodes prescribed by a physician and treated by a physician having a total duration of at least two weeks but less than four weeks during a 12-month period. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability pictures represented by the disability ratings assigned. Evaluations in excess of these ratings are provided for certain manifestations of these disabilities, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for the assigned ratings reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that schedular evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Code 5237; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). TDIU TDIU may be assigned where the schedular rating is less than total when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.16(a). Service connection is currently in effect for sleep apnea, benign prostatic hypertrophy, degenerative arthritis of the right acromioclavicular joint, status-post traumatic arthrosis of the right wrist, degenerative arthritis of the cervical spine, degenerative arthritis of the lumbar spine, right knee degenerative medial meniscus, tinnitus, sinusitis, gastroesophageal reflux disease, cholinergic urticaria, meibomian gland dysfunction with dysfunctional tear syndrome, otitis media of the left ear, nasal polyps, neck scar, abdominal scars, status-post arthroscopic surgery scars of the right shoulder, acne and neurological abnormalities of the right and left upper extremities. Sleep apnea has been assigned a 50 percent disability rating and the combined rating of the service-connected disorders is 90 percent. Accordingly, the schedular criteria for a TDIU have been met. The evidence shows that the Veteran's service-connected sleep apnea and cervical spine disability render him unable to secure or follow a substantially gainful occupation. According to the February 2016 VA examiner, the Veteran has not worked since 2011, when he left full-time employment due to the amount of loss of sleep he experienced due to his cervical spine disability. The Veteran reported could not sleep more than four hours without waking up from neck pain. The Veteran also reported that he had problems sitting for more than 20 minutes. The examiner indicated that the Veteran's disabilities impacted his ability to perform any type of occupational task. During the February 2016 hearing before the Board, the Veteran reported that he had to retire as an Army Chaplain due to his cervical spine disability. He stated that he would wake up from cervical spine pain and it interfered with his sleep. The Board finds that based on his level of disability, it is unlikely that he would be able to secure more than marginal employment. In summary, when reasonable doubt is resolved in the Veteran's favor, the Board concludes that his service-connected disabilities render him unable to secure or follow a substantially gainful occupation. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, a TDIU is warranted. ORDER An initial 30 percent disability rating for status-post traumatic arthrosis of the right wrist is granted, subject to regulations governing the payment of monetary benefits. Prior to February 25, 206, entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the cervical spine is denied. From February 25, 2016, a 20 percent rating for degenerative arthritis of the cervical spine is granted, subject to regulations governing the payment of monetary benefits. A separate compensable disability rating for radiculopathy of the right upper extremity is granted, subject to regulations governing the payment of monetary benefits. A separate compensable disability rating for radiculopathy of the left upper extremity is granted, subject to regulations governing the payment of monetary benefits. TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. . ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs