Citation Nr: 1624132 Decision Date: 06/15/16 Archive Date: 06/29/16 DOCKET NO. 11-09 474 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for thoracolumbar strain with degenerative arthritis. 2. Entitlement to an initial evaluation in excess of 10 percent for cervical strain with degenerative changes prior to April 14, 2010. 3. Entitlement to an initial evaluation in excess of 20 percent for cervical strain with degenerative changes beginning on or after April 14, 2010. 4. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 5. Entitlement to service connection for alcohol dependence, to include as secondary to service-connected PTSD. 6. Entitlement to service connection for a mood disorder, to include as secondary to service-connected PTSD. 7. Entitlement to service connection for a bilateral shoulder disorder, to include as secondary to service-connected thoracolumbar strain. 8. Entitlement to an effective date earlier than February 8, 2010 for the grant of a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Molly J. Steinkemper, Attorney ATTORNEY FOR THE BOARD K. Osegueda, Counsel INTRODUCTION The Veteran had active service from May 1969 to February 1971. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from October 2010, March 2013, and April 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In July 2014, the Board remanded the case for further development. The case has since been returned to the Board for appellate review. The Board notes that the Veteran's appeal originally included the issue of entitlement to service connection for headaches, to include as secondary to a traumatic brain injury (TBI). However, in April 2015, the RO granted service connection for post-concussive headaches as a residual of a TBI. Therefore, that issue no longer remains on appeal. The Veteran has also appealed the issues of entitlement to an initial evaluation in excess of 10 percent for post-concussive headaches and entitlement to an effective date earlier than August 10, 2006, for the grant of service connection for post-concussive headaches. See December 2015 supplemental statement of the case (SSOC). However, these issues have not yet been certified to the Board by the Agency of Original Jurisdiction (AOJ), indicating that the AOJ may be taking further action on these claims. Therefore, the Board does not have jurisdiction of those issues at this time. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In addition to the VBMS claims file, there is a Virtual VA paperless file associated with the Veteran's case. A review of the documents in the Virtual VA file reveals documents that are duplicative of evidence in the VBMS file or irrelevant to the issues on appeal. The issues of entitlement to service connection for alcohol dependence, a mood disorder, and a bilateral shoulder disorder 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's thoracolumbar spine strain with degenerative arthritis is not productive of forward flexion of the thoracolumbar spine to 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; or, incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. 2. Prior to April 14, 2010, the Veteran's cervical spine strain with degenerative arthritis was not productive of forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; combined range of motion of the cervical spine was not greater than 170 degrees; or, incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. 3. Since April 14, 2010, the Veteran's cervical spine strain with degenerative arthritis has not been productive of forward flexion of the cervical spine 15 degrees or less; favorable ankylosis of the entire cervical spine; or, incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. 4. The Veteran's PTSD has been manifested by symptoms causing occupational and social impairment with reduced reliability and productivity. He does not have occupational and social impairment with deficiencies in most areas. 5. The Veteran's claim for TDIU was received by VA on February 8, 2010, as part and parcel of an underlying claim for an increased rating for PTSD and his report that he had been unemployed since 2008. 6. It was not factually ascertainable that the Veteran was precluded from employment due to service-connected disabilities prior to the assigned effective date of February 8, 2010. There is nothing in the record upon which to conclude that there was an ascertainable increase in the severity of the Veteran's service-connected disabilities in the year prior to the date of receipt of his claim for TDIU. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for thoracolumbar spine strain with degenerative arthritis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Code 5242 (2015). 2. Prior to April 14, 2010, the criteria for an initial evaluation in excess of 10 percent for cervical spine strain with degenerative arthritis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Code 5242 (2015). 3. Since April 14, 2010, the criteria for an initial evaluation in excess of 20 percent for cervical spine strain with degenerative arthritis have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Code 5242 (2015). 4. The criteria for an increased rating greater than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2015). 5. The criteria for an effective date earlier than February 8, 2010, for the assignment of TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.157, 3.400 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular veteran's circumstances; that is, VA need not notify a veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular veteran's daily life. Vazquez-Flores v. Shinseki, supra. In this case, the Veteran is challenging the initial evaluations assigned following the grant of service connection for his thoracolumbar and cervical spine disabilities and the effective date following the grant of TDIU. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied. Moreover, with respect to the claims for an increased rating for PTSD and an earlier effective date, the RO provided the Veteran with a notice letters in February 2010, prior to the initial decision on the claims in October 2010. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the content of the letter satisfied the notice requirements. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified, relevant, and available post-service medical records, including VA treatment notes, Social Security Administration (SSA) medical reports, and private treatment notes, have been associated with the claims file and were reviewed by both the RO and the Board in connection with the claims. The Veteran has not identified any other outstanding records that are pertinent to this case. In addition, the duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded VA spine examinations in April 2010 and September 2014. He was afforded VA mental disorder and PTSD examinations in April 2010, January 2013, and September 2014. In addition, a VA medical opinion was provided in September 2010 with respect to the Veteran's PTSD symptoms and employability. As discussed below, the Board finds that the VA examinations in this case are adequate, as they are predicated on a review of the Veteran's medical history as well as on an examination, and they fully address the rating criteria that are relevant to rating the Veteran's thoracolumbar and cervical spine disabilities and PTSD. Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's thoracolumbar spine strain, cervical spine strain, or PTSD since he was last examined in September 2014. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2015). With regard to the July 2014 remand, the Board finds that the Appeals Management Center (AMC) substantially complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial compliance would be required, not strict compliance). Specifically, pursuant to the remand, the AMC obtained outstanding VA treatment records and associated them with the electronic claims file and provided the Veteran with adequate VA examinations that detailed the current severity and manifestations of his service-connected thoracolumbar and cervical spine disabilities and PTSD. In addition, the September 2014 VA examiner specifically addressed the question as to whether there were any neurological deficits related to the Veteran's thoracolumbar and cervical spine disabilities. Thus, there was compliance with the July 2014 remand. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 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. 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where a veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of the veteran's disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, where, as here, the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Spine 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. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain 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. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 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, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Veteran's thoracolumbar spine strain is currently assigned a 20 percent evaluation, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242. The Veteran's cervical spine strain is currently assigned a 10 percent evaluation prior to April 14, 2010, and a 20 percent evaluation as of April 14, 2010, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 indicates that degenerative arthritis should be evaluated under the General Rating Formula for Diseases and Injuries to the Spine. Under the General Rating Formula, 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 warranted when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; 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. A 20 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; 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 evaluation is warranted when there is forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted when there is unfavorable ankylosis of the entire cervical spine; forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diagnostic Codes 5235-5243. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For VA compensation purposes, normal range of motion for the cervical spine is 45 degrees of forward flexion, 45 degrees of extension, 45 degrees of left and right lateral flexion, and 80 degrees of left and right lateral rotation. Normal range of motion for the thoracolumbar spine is 90 degrees of forward flexion, 30 degrees of extension, 30 degrees of left and right lateral flexion, and 30 degrees of left and right lateral rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees, consisting of the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. See 38 C.F.R. § 4.71a, General Rating Formula, Note (2) and Plate V. Moreover, 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. See 38 C.F.R. § 4.71a, General Rating Formula, Note (5). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Id., Note (2). A. Thoracolumbar Spine In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial evaluation in excess of 20 percent for his thoracolumbar spine disability. For the entire period of the appeal, the Veteran has not been shown to have forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. In fact, during an April 2010 VA examination, the Veteran demonstrated forward flexion to 50 degrees with some tenderness beginning at 45 degrees. The April 2010 VA examiner noted that there was an increase in pain without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range of motion with repetitive use. During a September 2014 VA examination, the VA examiner indicated that the Veteran had forward flexion to 70 degrees with objective evidence of painful motion beginning at 60 degrees. In addition, after repetitive motion testing during the September 2014 VA examination, the Veteran still demonstrated 70 degrees of forward flexion. He had no additional limitation of motion due to repetitive motion testing. Further, the September 2014 VA examiner expressly noted that there was no ankylosis of the spine. In addition, there is no indication that the Veteran has had incapacitating episodes with a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. As previously noted, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). In fact, the evidence of record shows that the Veteran has not been prescribed bed rest by a physician at any point during the appeal. Moreover, the September 2014 VA examiner stated that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. As such, to the extent this criteria is for application, the Veteran has not been shown to have met the criteria for an increased evaluation under Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board further finds that a separate disability rating is not warranted because the evidence does not demonstrate that the Veteran suffers from a separate neurological disability distinct from his already service-connected lumbar spine disability. See Bierman v. Brown, 6 Vet. App. 125, at 129-32 (1994). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). During the April 2010 VA examination, the VA examiner noted that there was no atrophy of the thoracic sacrospinals, and motor, sensory, and reflex examinations of the lower extremities were normal. During the September 2014 VA examination, the VA examiner noted that the Veteran had no neurologic abnormalities or findings related to a thoracolumbar spine condition, such as bowel or bladder problems or pathologic reflexes. In addition, the September 2014 VA examiner noted that muscle strength testing of the lower extremities was normal; there was no atrophy; reflex and sensory examinations of the lower extremities were normal; straight leg raise testing was negative bilaterally; and there was no radicular pain or any other signs or symptoms due to radiculopathy. Moreover, the September 2014 VA examiner expressly stated, "The [V]eteran on this examiner's neurological exam based on today's 'objective' findings are 'normal,' thus I find no evidence of cervical or lumbar radiculopathy." Thus, the Board concludes that the evidence weighs against a finding that the Veteran suffers from additional neurological deficiency so as to warrant a separate disability rating under the diagnostic codes pertinent to rating neurological disorders. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an initial evaluation in excess of 20 percent for the Veteran's thoracolumbar spine disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. In this regard, the Board observes that the Veteran complained of pain during the April 2010 and September 2014 VA examinations. However, the effect of the pain in the Veteran's back is contemplated in the currently assigned 20 percent evaluation. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. In fact, the April 2010 and September 2014 VA examiners indicated that the Veteran was able to perform repetitive-use testing without any additional limitation in the range of motion. The Court has held that pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Therefore, the Board finds that the Veteran's thoracolumbar spine strain warrants a 20 percent rating, and no higher. B. Cervical Spine In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent prior to April 14, 2010, or in excess of 20 percent on or after April 14, 2010, for his cervical spine disability. For the period prior to April 14, 2010, the Veteran has not been shown to have forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees. In fact, during an April 2010 VA examination, the examiner noted that the Veteran demonstrated flexion to 30 degrees with some tenderness beginning at 25 degrees. Although the April 2010 VA examiner noted that there was an increase in pain, it was noted that there was no additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range of motion with repetitive use. In addition, for the period prior to April 14, 2010, the evidence does not show that the Veteran's combined range of motion of the cervical spine was not greater than 170 degrees. In fact, during the April 2010 VA examination, the Veteran demonstrated a combined range of motion of the cervical spine of 170 degrees. For the period beginning on or after April 14, 2010, the Veteran has not been shown to have forward flexion of the cervical spine to 15 degrees or less based on the range of motion. Moreover, the Veteran has not been shown to have favorable ankylosis of the entire cervical spine. In fact, during the September 2014 VA examination, the VA examiner indicated that the Veteran had forward flexion to 35 degrees with objective evidence of painful motion beginning at 30 degrees. In addition, after repetitive motion testing during the September 2014 VA examination, the Veteran still demonstrated 35 degrees of forward flexion. He had no additional limitation of motion due to repetitive motion testing. Further, the September 2014 VA examiner expressly noted that there was no ankylosis of the cervical spine. Moreover, based on the aforementioned range of motion findings, it appears that the Veteran's entire cervical spine is not totally fixated or immobile. While the noted ranges of motion were limited by pain at times, these findings are consistent with and fully contemplated by the 20 percent rating currently assigned for the period beginning on April 13, 2010. In addition, there is no indication that the Veteran has had incapacitating episodes meeting the durational requirement for a rating under the intervertebral disc syndrome rating criteria noted above. In fact, the Veteran routinely denied a history of incapacitating episodes during the VA examinations discussed above. During the April 2010 VA examination, the Veteran expressly denied any periods of complete incapacitation during the previous year due to his cervical spine disability. The September 2014 VA examiner also specifically noted that the Veteran did not have intervertebral disc syndrome of the cervical spine. As such, the Veteran has not been shown to have met the criteria for an increased evaluation under Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Despite the Veteran's reports that he had an occasional tingling sensation in his left upper extremity during the April 2010 VA examination and his description of occasional pain down his right arm during the September 2014 VA examination, the Board finds that the evidence weighs against a finding that the Veteran has any additional neurological deficiency due to his cervical spine disability. During the April 2010 VA examination, the Veteran indicated that he did not have a constant, persistent tingling sensation in his upper extremities. Moreover, the April 2010 VA examiner noted that motor, sensory, and reflex examinations of the upper extremities were normal. In addition, during the September 2014 VA examination, the VA examiner noted that the Veteran had no neurologic abnormalities or findings related to a cervical spine condition, such as bowel or bladder problems due to cervical myelopathy. Furthermore, the September 2014 VA examiner noted that muscle strength testing of the upper extremities was normal; there was no atrophy; reflex and sensory examinations of the upper extremities were normal; and there was no radicular pain or any other signs or symptoms due to radiculopathy. The September 2014 VA examiner also expressly stated, "The [V]eteran on this examiner's neurological exam based on today's 'objective' findings are 'normal,' thus I find no evidence of cervical or lumbar radiculopathy." Thus, the Board concludes that the evidence weighs against a finding that the Veteran suffers from additional neurological deficiency so as to warrant a separate disability rating under the diagnostic codes pertinent to rating neurological disorders. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, increased evaluations for the Veteran's cervical spine disability are not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 10 and 20 percent ratings, and no higher. In this regard, the Board observes that the Veteran complained of pain on numerous occasions. While pain alone does not constitute functional loss, the Court has clearly indicated that the Board must consider the effects of pain, particularly as to any adverse impact on the normal working movements of the body such as excursion, strength, speed, coordination, and endurance; it is the presence of this functional loss that is the relevant question in assigning disability evaluations. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). However, the effect of the pain in the Veteran's cervical spine is contemplated in the currently assigned 10 and 20 percent evaluations, and the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant increased evaluations. Therefore, the Board finds that the Veteran's cervical spine strain warrants a 10 percent rating prior to April 14, 2010, and a 20 percent rating beginning on April 14, 2010, and no higher. PTSD The Veteran's PTSD is currently assigned a 50 percent disability evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 50 percent rating is warranted when the psychiatric disorder results in 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 warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in 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. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The Board notes that the regulations were recently revised to incorporate the Fifth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V) rather than the Fourth Edition (DSM-IV). However, these provisions only apply to cases received by or pending before the AOJ on or after August 4, 2014. The change does not apply to cases certified to the Board prior to that date. In this case, the Veteran's claim was certified to the Board prior to August 4, 2014; therefore, the regulations pertaining to the DSM-IV are for application. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran does not meet the criteria for a 70 percent evaluation, or higher, for his PTSD. 38 C.F.R. § 4.7. As noted above, a 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in 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. The evidence of record does not show that the Veteran has obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene. In an April 2010 VA examination report, the VA examiner noted that the Veteran reported depressive symptoms, including feeling unhappy. He also endorsed sleep disturbance, limited interests, and decreased energy. There was no suicidal ideation or history of violence or assaultiveness. The VA examiner noted that the Veteran's clothes were clean, and his psychomotor activity was unremarkable. His speech was spontaneous and clear. His affect was constricted, and his mood was dysphoric. The Veteran's attention was intact, and he was oriented to person, time, and place. His thought process and content were unremarkable. He had no delusions, and his judgment and insight were intact. He did not demonstrate inappropriate behavior, and he denied obsessive or ritualistic behavior. His memory was also normal. The Board notes that the Veteran did report having irritability during the April 2010 VA examination, but the evidence does not suggest that he has impaired impulse control. In fact, the April 2010 VA examiner noted that the Veteran did not have any violent behavior and that his impulse control was good. In addition, a January 2013 VA examiner noted that the Veteran did not demonstrate any unusual mannerisms or behaviors. His speech and mood were normal and appropriate to content of thought. His thought process was logical, and his thought content revealed no unusual material, such as hallucinations or delusions. His sensorium was clear, and he was oriented to time, person, place, and situation. His judgment was not impaired, and he was not a danger to himself or others. During the January 2013 VA examination, the Veteran endorsed symptoms of anxiety and chronic sleep impairment. During a September 2014 VA examination, the examiner noted that the Veteran's responses to questions were brief and non-elaborative; he was oriented in all spheres; his attention and concentration were intact; his insight and judgment were intact; and his remote, recent, and immediate memory were intact. The examiner noted that the Veteran had a depressed mood; anxiety; chronic sleep impairment; and difficulty in establishing and maintaining effective work and social relationships. The Board finds that the Veteran's anxiety and depression have not been near-continuous such that it affected his ability to function independently, appropriately, and effectively. The evidence shows that he has good hygiene, as well as appropriate communication and behaviors. He has not had any legal problems and denied any violent behavior. There is also no indication that he requires assistance. Thus, while the Veteran may have been experiencing anxiety and/or depression, the Board finds that the evidence of record shows that the severity of such symptoms are more appropriately described as a "disturbance of motivation and mood" under the criteria for a 50 percent evaluation. The severity did not rise to the level of compromising his ability to independently and appropriately function as the 70 percent rating criteria contemplate. With regard to social impairment, the Board notes that the Veteran has reported increasing social isolation. During the April 2010 VA PTSD examination, the Veteran reported that he had been married to his wife for 25 years and that he lived with his wife on a farm. He also stated that he had two adult children that lived within 30 miles of him. During the January 2013 VA mental disorders and TBI examination, the Veteran stated that he remained married to his wife, but they lived separately and met up every three or four days. He reported that he liked being alone. During the September 2014 VA examination, the Veteran reported that he was married to his wife for 30 years. He indicated that they lived four miles away from each other and that he saw his wife approximately once per week. He stated that he had very little contact with his extended family. The January 2013 VA examiner indicated that the Veteran's social interaction was routinely appropriate. However, during the April 2010 VA examination, the Veteran stated that he had no friends outside of his family, but he went to the bar to drink and socialize. In addition, during the September 2014 VA examination, the Veteran maintained that he avoided interaction with other people. He noted that he had very little social activity, but he also stated that he got together with friends "every now and then." With regard to occupational impairment, the Veteran has reported that he was unemployed throughout the appeal. During the September 2014 VA examination, the Veteran reported that he last worked six years ago before he sold his heating, air conditioning, and plumbing business. During the April 2010 VA examination, the Veteran indicated that he did not attribute his unemployment to his PTSD. In a September 2010 VA medical opinion, a VA examiner noted that the Veteran described unemployment due to the downturn in the economy and an inability to maintain jobs as an independent plumber. The examiner noted that the Veteran's PTSD symptoms would likely cause some reduction in productivity if he were to be gainfully employed. He also opined that the Veteran's symptoms would have a moderate impact on his ability to perform occupationally, but his PTSD symptoms alone would not cause him to be unemployable. Moreover, the April 2010 VA examiner opined that the Veteran's history indicates that his PTSD has an impact on his ability to be fully employed and it has constricted his family functioning, interpersonal relations, and recreational activity to some extent. The January 2013 and September 2014 VA examiners indicated that the Veteran had occupational and social impairment with reduced reliability and productivity caused by his PTSD. These statements were made my examiners who reviewed the claims file, considered the Veteran's reported history and subjective complaints, and performed a mental condition. Their conclusions clearly weigh against a disability evaluation in excess of 50 percent. Overall, the Veteran has not demonstrated symptoms consistent with the general level of impairment warranting a 70 or 100 percent evaluation, or akin to the symptoms listing as found in the rating criteria. Mauerhan, supra. The evidence also does not show that the Veteran had occupational and social impairment with deficiencies in most areas, or total occupational and social impairment, consistent with a higher evaluation. Finally, the Board acknowledges the April 2010 and January 2013 VA examiners assigned the Veteran a GAF score of 55. A GAF score between 41 and 50 indicates moderate symptoms. See 38 C.F.R. §§ 4.125, 4.130. In this case, the GAF score assigned is but one factor for consideration in a rating. While considering the GAF score of record as part of the overall social and occupational functioning picture, the Board finds the narrative contained in the VA examination reports to be the most probative evidence of the Veteran's psychological symptomatology. When all of the evidence and findings contained therein are considered in totality, including the degree of functioning as evidence by the GAF score, the Board finds that that the Veteran has been shown to have occupational and social impairment with reduced reliability and productivity. The Board concludes that the preponderance of the evidence is against a finding that an increased rating in excess of 50 percent is appropriate, and the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. Extraschedular Consideration In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's thoracolumbar and cervical spine disabilities and PTSD are so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology, which include pain, irritability, and sleep impairment. As discussed above, such symptoms are contemplated by the schedular criteria set forth in the applicable diagnostic codes. Indeed, the rating criteria for mental disorders contemplate the overall effect of all of his symptomatology on his occupational and social functioning. The Board also notes that, for all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board finds that the schedular criteria reasonably describe the Veteran's disability picture in this case. Thus, it cannot be said that the available schedular evaluations for these disabilities are inadequate. As discussed above, there are higher ratings available under the diagnostic codes, but the Veteran's disabilities are not productive of such manifestations. Finally, the Board notes that, under the Federal Circuit Court's recent holding in the case of Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In any event, at this juncture, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms that have not been attributed to a specific service-connected disability. Indeed, the Veteran and his representative have not asserted otherwise. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected disabilities under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). Effective Date The effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. A claim for TDIU is a claim for increased compensation if the "disability upon which entitlement to TDIU is based has already been found to be service connected." Rice v. Shinseki, 22 Vet. App. 447, 453-4 (2009). Accordingly, the assignment of an effective date is controlled by the criteria for assigning the effective date for an increased rating. Dalton v. Nicholson, 21 Vet. App. 23 (2007); Wood v. Derwinski, 1 Vet. App. 367, 369 (1991). An exception to that rule applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). The United States Court of Appeals for Veterans Claims (Court) and VA General Counsel have interpreted the laws and regulations pertaining to the effective date for an increase as follows: If the increase occurred within one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C.A. § 5110(b)(2); Harper at 126; 38 C.F.R. § 3.400(o)(1)(2) (2014); VAOPGCPREC 12-98 (1998). When considering the appropriate effective date for an increased rating, VA must consider the evidence of disability during the period one year prior to the application. See Hazan v. Gober, 10 Vet. App. 511 (1997). In this case, the effective date for TDIU would be the later of the date of receipt of claim or the date entitlement arose. See 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400(b)(2) (ii). The Veteran filed a claim for TDIU on February 8, 2010. Based on findings from a September 2010 VA examination, the RO granted TDIU, effective the date of the claim. There are no documents on record filed prior to February 2010 that can be considered as a formal or informal claim for an increased rating or for TDIU. Indeed, there has been no dispute as to the date of application. As noted above, the Court held that the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has, therefore, considered whether it is factually ascertainable that the Veteran was unemployable within one year of receipt of his claim. During an April 2010 VA PTSD examination, the Veteran indicated that he was a self-employed plumber for seven years until approximately one and a half years earlier. He stated that he had been unemployed for one and a half years because he was not getting any jobs, so he stopped working. He did not contend that his unemployment was due to the effects or symptoms of his PTSD. In a September 2010 VA medical opinion, the VA examiner noted that the Veteran described his unemployment as being related to the downturn in the economy and not having jobs as an independent plumber. The VA examiner opined that the Veteran's PTSD symptoms would likely cause some reduction in productivity if he was gainfully employed, but they would not cause him to be unemployable. During a September 2010 VA general medical examination, the Veteran stated that he last worked full-time as a plumber until approximately two years earlier. He also reported that he sold his plumbing business at that time. He maintained that problems with his service-connected PTSD, spine disabilities, and headaches were instrumental in his difficulty with occupational duties. In July 2010, the Veteran stated that he last worked full-time as a self-employed plumber in October 2008. He noted that he stopped working due to his disabilities. Regardless, in both instances, the Veteran maintained that he was unemployed more than one year prior to his claim for TDIU; thus, any increase in his service-connected disabilities rendering him unemployable would be effective from the date of the claim, which was February 8, 2010. 38 U.S.C.A. § 5110(b)(2); see also 38 C.F.R. § 3.400(o) (2); Harper v. Brown, 10 Vet. App. 125 (1997). It was not factually ascertainable that the Veteran was precluded from employment due to service-connected disabilities prior to the assigned effective date of February 9, 2010. There is nothing in the record upon which to conclude that there was an ascertainable increase in the severity of the Veteran's service-connected disabilities in the year prior to the date of receipt of his claim for TDIU. The evidence shows that the Veteran was granted disability benefits from the Social Security Administration (SSA) in an August 2011 decision. The effective date of that award was June 15, 2010, after the effective date assigned for TDIU. In summary, the Board finds that an effective date earlier than February 8, 2010, for the assignment of TDIU is not warranted. ORDER An initial evaluation in excess of 20 percent for thoracolumbar strain with degenerative arthritis is denied. An initial evaluation in excess of 10 percent for cervical strain with degenerative changes prior to April 14, 2010, is denied. An initial evaluation in excess of 20 percent for cervical strain with degenerative changes on or after April 14, 2010, is denied. An evaluation in excess of 50 percent for PTSD is denied. An effective date earlier than February 8, 2010 for the grant of TDIU is denied. REMAND A review of the record shows that the prior directives from the July 2014 remand were not completed with respect to the remaining issues on appeal. The United States Court of Appeals for Veterans Claims (Court) has held "that a remand by this Court or the Board confers on the veteran or other claimant, as a matter of law, a right to compliance with the remand orders." Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, compliance with the terms of the remand is necessary prior to further appellate review, and if not, "the Board itself errs in failing to ensure compliance." Id. In the July 2014 remand, the Board noted that the January 2013 VA opinion regarding entitlement to service connection for alcohol dependence secondary to PTSD was inadequate because the VA examiner's rationale was conclusory and provided no rationale. The examiner had opined that the alcohol dependence was not caused by or persistently aggravated by the Veteran's service-connected PTSD. The examiner referenced the Archives of General Psychiatry in his support of his opinion. The Board remanded the issue for an additional VA examination. In a September 2014 VA PTSD examination report, the examiner opined that it was less likely as not that the Veteran's alcohol dependence is caused or aggravated by his service-connected PTSD or is otherwise etiologically related to his active service. The examiner indicated that medical research does not support causation or aggravation of alcohol dependence as a result of PTSD. He provided no further rationale for his opinion. Thus, the Board finds that the case should be returned to the VA examiner for a clarifying opinion with an adequate rationale. Moreover, as the Board noted in the July 2014 remand, the issue of entitlement to service connection for a mood disorder secondary to service-connected PTSD is inextricably intertwined with the Veteran's claim for alcohol dependence secondary to PTSD. Therefore, the claim for a mood disorder must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue. In addition, in the July 2014 remand, the Board noted that the January 2013 VA examination regarding the Veteran's claimed bilateral shoulder disorder was inadequate because the rationale was significantly based on the premise that "there is essentially no documentation about this nor any sequence of events over time that would help support that nexus, at least based within a reasonable time frame after discharge." The claim was remanded for an additional VA examination to consider the Veteran's assertions of symptomatology after his separation from service. The Veteran was afforded a VA shoulders examination in September 2014. The VA examiner opined that he Veteran's bilateral shoulder issues are less likely than not caused by, related to, or aggravated by his service-connected thoracolumbar spine disability or active service. The examiner noted that the Veteran's separation examination showed a normal examination of the bilateral upper extremities and that his report of medical history was silent for any shoulder issues. The examiner stated that there was not ample evidence to support the Veteran's claim. However, the examiner's opinion was not responsive to the July 2014 remand directives. Namely, the examiner did not consider the Veteran's assertions of symptomatology after his separation from service. Therefore, the case should be returned for a clarifying opinion. Accordingly, the case is REMANDED for the following action: 1. The AOJ should contact the Veteran and request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for alcohol dependence, a mood disorder, and a bilateral shoulder disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should all secure any outstanding, relevant VA medical records. 2. After completing the foregoing development, the case should be returned to the September 2014 VA examiner (or if he is unavailable, to another suitably qualified examiner) for a medical opinion to determine the nature and etiology of any mood disorder and alcohol dependence that may be present. An additional examination of the Veteran should be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, service personnel records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, such as observable symptomatology. If there is a medical basis to support of doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran has a mood disorder and alcohol dependence that were either caused by or permanently aggravated by his service-connected PTSD or that are otherwise etiologically related to military service. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should refer the Veteran's claims file to the September 2014 VA examiner, or, if he is unavailable, to another suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any current bilateral shoulder that may be present. An additional examination of the Veteran should be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the electronic claims file, including the Veteran's service treatment records, and post-service medical records. The Veteran has essentially asserted that he had pertinent symptomatology after his separation from service. The examiner should note that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's current left shoulder disorder was either caused by or permanently aggravated by his service-connected thoracolumbar spine disability or is otherwise etiologically related to military service, to include a fall from a truck during service. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The AOJ should review the medical opinions to ensure that they are in compliance with this remand. If the report is deficient, the AOJ should implement corrective procedures. 5. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 6. When the development has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the appellant and his representative should be furnished a SSOC and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs