Citation Nr: 1705142 Decision Date: 02/21/17 Archive Date: 02/28/17 DOCKET NO. 11-00 235 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an evaluation of greater than 20 percent for service-connected multi-level degenerative disc disease. 2. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Calvin Hansen, Esq. ATTORNEY FOR THE BOARD L. Bush, Associate Counsel INTRODUCTION The Veteran served in the U.S. Army from January 1969 to October 1970. This matter came to the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision of the Lincoln, Nebraska Regional Office (RO) which, among other things, proposed to reduce the disability evaluation of the Veteran's multi-level degenerative disc disease from 20 percent to 10 percent and denied a TDIU. In October 2010, the RO effectuated the proposed reduction effective January 1, 2011. The Veteran appealed these decisions and, in May 2016, the Board found that the RO had improperly reduced the disability evaluation of the Veteran's multi-level degenerative disease and restored it to a 20 percent evaluation effective January 1, 2010. The Board went on to remand the issue of entitlement to an evaluation greater than 20 percent for multi-level degenerative disc disease and TDIU for further development. As the actions specified in the remand have been completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's multi-level degenerative disc disease is manifested by back pain that also localizes over the hip area, fatigue, and decreased motion; however, the forward flexion of his thoracolumbar spine is not 30 degrees or less, there is no favorable ankylosis of the entire thoracolumbar spine, and there have been no incapacitating episodes. 2. 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 evaluation greater than 20 percent for the Veteran's service-connected multi-level degenerative disc disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including §§ 4.7, 4.71a, Diagnostic Codes 5242, 5243 (2016). 2. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.3, 4.7, 4.15, 4.16, 4.18, 4.19 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. Id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. It should not be assumed that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record, and every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. II. Duties to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). The Veteran was provided the relevant notice and information in March 2009 prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He has not alleged any notice deficiency during the adjudication of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). With regard to VA's duty to assist the Veteran, the claims file contains all pertinent service treatment records (STRs), post-service treatment records, and lay statements in support of the claim. Additionally, the Veteran was afforded VA examinations which, collectively, contain a description of the history of the disability at issue, document and consider the relevant medical facts and principles, and provide opinions regarding the etiology of the Veteran's claimed condition. VA's duty to assist with respect to obtaining relevant records and an examination have been met. 38 C.F.R. § 3.159(c); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). III. Increased Rating a. Analysis Service connection was established for the Veteran's multi-level degenerative disc disease in June 2009 and a 20 percent disability rating was assigned effective March 2009, the date of the original claim. The Veteran maintains that he should receive a higher rating for his disability. Disability ratings are determined by evaluating the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). In accordance with 38 C.F.R. §§ 4.1, 4.2 (2016) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the Veteran's service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The Board is of the opinion that this case presents no evidentiary considerations, except as noted below, that would warrant an exposition of the remote clinical history and findings pertaining to the disability at issue. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2016); see Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Diagnostic Codes 5237 through 5243 are applicable to the spine. The Veteran's multi-level degenerative disc disease is currently rated as 20 percent disabling pursuant to Diagnostic Code 5242. The current General Rating Formula for Diseases and Injuries of the Spine provides that 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 20 percent rating is warranted for forward flexion of the thoracolumbar spine that is greater than 30 degrees but not greater than 60 degrees or a combined range of motion of the thoracolumbar spine not greater than 120 degrees. The 30 percent rating criteria is not relevant to the current appeal as it concerns flexion and ankylosis of the cervical spine only. An evaluation of 40 percent is warranted for forward flexion of the thoracolumbar spine 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. An evaluation of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. An evaluation of 100 percent requires unfavorable ankylosis of the entire spine. Additionally, Diagnostic Code 5243 governs ratings of intervertebral disc syndrome, either on the total duration of incapacitating episodes over the past 12 months, or by combining under 38 C.F.R. § 4.25 (combined rating tables) separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, which ever method results in the higher evaluation. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. A maximum 60 percent rating is warranted when rating based on incapacitating episodes, and such is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. 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. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 38 C.F.R. §§ 4.40, 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Board finds that the Veteran's multi-level degenerative disc disease most closely approximates the criteria for a 20 percent disability rating. The Veteran was afforded a VA examination in April 2009. At the examination, the Veteran reported daily, constant pain in his low back pain in the lumbar midline region. He stated that he self-treated with pain medication, rest, stretches, and hot and cold packs as needed. He maintained that the pain interrupted his sleep. No incapacitating episodes of spine disease were reported. Upon physical examination, the examiner noted that he was unable to stand more than a few minutes and had an antalgic gait. The examiner did not find thoracolumbar spine ankylosis. X-ray testing showed mild to moderate degenerative disc disease. When testing the Veteran's range of motion, she found that the Veteran's forward flexion was greater than 30 degrees but did not exceed 60 degrees and his combined range of motion was not greater than 120 degrees. He was diagnosed with multi-level degenerative disc disease. This examination was the basis of the grant of service connection and the 20 percent disability rating. See April 2009 VA Examination. The Veteran began physical therapy in December 2009. A December 2009 physical therapy note indicated that the Veteran reported pain and had severely decreased flexion and moderately decreased extension due to his lower back disability. Subsequent physical therapy notes show that the Veteran consistently reported lower back pain. He attended 6-8 sessions and engaged in traction and exercise. At his final session, it was noted that the Veteran had, "failed to meet his functional discharge goals, stating that [low back pain] remains at 6-7/10 level consistently." See December 2009-February 2010 Physical Therapy Notes. The Veteran was provided another VA examination in March 2010 to ascertain whether an increased rating was required. The examiner indicated that the Veteran's clinical records were not available for review. At that examination, the Veteran made the same subjective reports of daily, constant low back pain and stated that his symptoms were worsening. He reported no incapacitating episodes of spine disease. Upon physical examination, the examiner found that the Veteran could still only stand for brief periods of time and maintained an abnormal, antalgic gait. The examiner did not find thoracolumbar spine ankylosis. However, his forward flexion had increased to 0 to 75 degrees with pain at 75 degrees on his active and passive range of motion. His combined range of motion was 190 degrees. This examination was the basis of the proposed rating reduction of the Veteran's disability rating from 20 percent to 10 percent, which ultimately went into effect in January 2011. See March 2010 VA Examination. A third VA examination was provided in May 2014. The Veteran again reported midline lumbar pain, achiness, tightness, and stiffness. He described radiculopathy symptoms. He discussed his self-treatment methods and stated that he goes for chiropractic care during flare-ups. He also stated that he wears a back brace on a regular to occasional basis, particularly during times of increased activity. Upon physical examination, the examiner once again found that the Veteran could stand for limited periods of time, but at that time did not report observing an abnormal gait. The examiner did not find ankylosis of the spine. He found mild symptoms of radiculopathy in the Veteran's lower extremities to include intermittent pain, parathesias and/or dysesthesias, and numbness. The examiner diagnosed the Veteran with invertebral disc syndrome (IVDS) of the thoracolumbar spine, but also noted that the Veteran had no incapacitating episodes over the past 12 months due to IVDS. The Veteran's forward flexion was still 0 to 75 degrees, although at this examination, he reported pain at 60 degrees. In a May 2016 decision, the Board found that the reduction of the Veteran's disability rating effective January 2011 from 20 percent to 10 percent for his multi-level degenerative disc disease was improper as at that time the RO made no findings that there was sustained improvement in the Veteran's condition. The Board restored the Veteran's disability rating to 20 percent, effective January 2011 and remanded the issue of whether an evaluation in excess of 20 percent was warranted to allow the submission of any additional clinical documentation. In a letter received in May 2016, the Veteran stated that he had no additional other health care records to submit. Therefore, the evidence of record is complete and adjudication of the issue whether a higher evaluation is warranted can proceed without prejudice to the Veteran. The Board accepts that the Veteran is competent to report on his functional impairment. Laypersons are without a doubt competent to report symptoms and events and their effects that they experience through their senses. See 38 C.F.R. § 3.159 (a)(2); Charles v. Principi, 16 Vet. App 370, 374 (2002). Furthermore, the Board finds the Veteran's own reports of symptomatology to be credible. However, the schedular criteria for the low back disability are predicated in the main on medical findings, not subjective symptoms and, here, the medical findings, to include consideration of the De Luca factors and functional loss, do not more nearly reflect the criteria for the next higher evaluation. The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned evaluation is appropriate for the Veteran's disability. At the most recent VA examination in May 2014, the Veteran continued to report pain. However, upon range of motion testing, it was shown that the Veteran's range of motion, combined with the absence of ankylosis, lands him squarely within a 10 percent disability evaluation as the forward flexion of the thoracolumbar spine was greater than 60 degrees, but not greater than 85 degrees, his combined range of motion was greater than 120 degrees but not greater than 235 degrees. As the Board noted in its prior decision, the RO's attempt to reduce the Veteran's disability rating from 20 percent to 10 percent was improper as sustained improvement was not shown. However, while sustained improvement has not been demonstrated, neither has objective evidence of worsening of the Veteran's condition. In order to be evaluated at 40 percent under DC 5242, the next highest rating applicable to the Veteran's disability, the Veteran must have forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The medical evidence shows neither. Additionally, while the Veteran has been diagnosed with IVDS, the medical evidence does not support a finding that his disability has resulted in incapacitating episodes like those discussed in DC 5243. In conclusion, a disability evaluation in excess of 20 percent for the Veteran's service-connected multi-level degenerative disc disease is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102 (2016). b. Extraschedular Consideration Finally, the Board has also considered whether the Veteran's disabilities warrant referral for extraschedular consideration. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321 (b)(1) (2016). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluations for his level of impairment. In other words, he does not have any symptoms from his service-connected disorders that are unusual or different from those contemplated by the schedular criteria. Moreover, the Board again notes that the Veteran has been provided a 20 percent rating under Diagnostic Code 5242 and there is no objective medical evidence of worsening. Thus, the Veteran's reported symptoms have been appropriately compensated. Therefore, the available schedular evaluations for his service-connected disability are adequate. According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be entitled to "consideration [under 38 C.F.R. § 3.321 (b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321 (b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. Moreover, the Board notes that the Veteran is already in receipt of a total rating, although this decision will grant retroactive benefits. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321 (b)(1) (2016). TDIU Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1). Total ratings are authorized for any disability or combination of disabilities for which the rating schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). A TDIU may be assigned 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. The service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue will be addressed in both instances. 38 C.F.R. § 4.16(a), (b). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). If a veteran's disabilities do not meet the objective combined rating percentage criteria of 38 C.F.R. § 4.16(a), it then becomes necessary to consider whether the criteria for referral for extraschedular consideration are met under § 4.16(b) criteria. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Submission to the Director, Compensation and Pension Service, for extraschedular consideration is warranted in all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). 38 C.F.R. § 4.16(b). Individual unemployability must be determined without regard to any non-service connected disabilities or a veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran's favor. 38 C.F.R. § 4.3. In Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). In evaluating a veteran's employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner's opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16(a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). In this case, the Veteran has advanced being unable to secure (obtain) or maintain (follow) substantially gainful employment due to service-connected disabilities. After a review of all the evidence, lay and medical, the Board finds that entitlement to TDIU is warranted. Currently, the Veteran has a combined evaluation of 70 percent for his service-connected disabilities. The Veteran is currently service-connected for multi-level degenerative disc disease (rated as 20 percent disabling), right ankle fracture (rated as 20 percent disabling), tinnitus (rated as 10 percent disabling), right knee strain associated with fracture (rated as 10 percent disabling), right lower extremity radiculopathy (rated as 10 percent disabling), left lower extremity radiculopathy (rated as 10 percent disabling), bilateral hearing loss (rated as 10 percent disabling), right knee strain associated with limitation of extension (rated as 0 percent disabling), and scar associated with right knee strain with limitation of extension (rated as 0 percent disabling). He therefore meets the schedular criteria of TDIU, as his orthopedic disabilities equal 40 percent in combination. The record shows that the Veteran has a high school diploma but does not suggest any further completed education or training. While in service, his military operational specialty (MOS) was that of a clerk typist. See DD Form 214. Post-service, the Veteran reported that he worked in construction for about fifteen years, until the early 2000s. Following his time in construction, he worked primarily in auto restoration and sales. The Veteran consistently reported that problems with his back, knee, and ankle (all service-connected) made it increasingly difficult to continue this type of employment. He stopped working in 2008. The Board is aware, however, that the crucial question is not whether the Veteran is actually unemployed but whether he is capable of performing the physical and mental acts required by employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In addition, the Board may consider the Veteran's educational and work history when determining employability. 38 C.F.R. §§ 3.341, 4.16, 4.19. Each position that the Veteran has held both since service required him to engage in physical activity/labor. The record reveals that the Veteran has consistent pain in his back, right knee and ankle that cause him difficulty walking or standing for prolonged periods. His previous employment experience required the ability to stand or move around a lot while working. The record does not reflect that he ever held a sedentary position since his time in service nearly 50 years ago, nor does it reflect that he has training and/or education to engage in these types of positions. A medical opinion provided by a VA examiner indicates that the Veteran's service-connected conditions would likely result in some functional impairment to occupational duties that would require bending, lifting, twisting, climbing, crawling, carrying, and prolonged weight-bearing. Many of the aforementioned tasks are required by those engaged in construction or auto restoration and sales. The examiner also went on to find that it is as least as likely as not that the Veteran would have difficulty following and maintaining substantial gainful employment in occupations that would require light to moderate physical activity due to his service-connected conditions. Although the examiner opined that the Veteran would not be completely precluded from following or maintaining employment of a sedentary nature, as previously mentioned, the evidence of record does not support a finding that the Veteran has the skills or training to pursue wholly sedentary employment opportunities. See May 2014 VA Examination. Based on all the evidence of record, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran is precluded from securing and following substantially gainful employment due to the effects of his service-connected disabilities, specifically his low back condition, right knee, and right ankle disabilities. The Board finds that the evidence supports that he would be unable to perform labor akin to that which he is educated and trained to perform. Therefore, the Board concludes that TDIU is warranted. ORDER Entitlement to an evaluation of greater than 20 percent for service-connected multi-level degenerative disc disease is denied. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is granted. ____________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs